Indian Pediatr 2019;56:304-306|
of Pediatric Scrub Typhus in Odisha, India
Mahesh Prasad Mohanta2,
and Manoranjan Ranjit1
From 1ICMR-Regional Medical Research
Centre, 2Naba Diganta Primary Care Hospital, Keonjhar, 3Apollo
Hospitals, and 4All India Institute of Medical Sciences;
Bhubaneswar, Odisha, India.
Correspondence to: Dr Manoranjan Ranjit, Scientist-F,
ICMR-Regional Medical Research Centre, Chandrasekharpur,
751 023, Odisha.
Received: March 29, 2018;
Initial review: August 20, 2018;
Accepted: February 21, 2019.
Objective: To investigate the distribution and
clinical profile of scrub typhus infection among children with acute
febrile illness in Odisha. Methods: Children (<15 y) presenting
with acute fever (>5 days) in 4 agro-climatic zones from June to
November 2017 were evaluated. Patients were screened for malaria,
leptospira, dengue, typhoid and scrub typhus. Scrub typhus was confirmed
by IgM ELISA and PCR. Results: Out of 413 cases
examined, 48.7% were positive for scrub typhus, and 5.5% of them
developed systemic complications. Eschar was found in 17.9% of cases.
Five days treatment of Doxycycline and/or Azithromycin was clinically
effective against scrub typhus. Conclusion: Our study highlights
that scrub typhus is one of the causes of high morbidity in children
during rainy months in Odisha.
Keywords: Acute encephalitis syndrome, Acute febrile
illness, Etiology, Rickettsia.
crub typhus, caused by Orientia tsutsugamushi
is rife in Southeast Asian region and re-emerging as a major cause of
acute febrile illness (AFI) in Indian subcontinent, especially among
children . The disease is characterized by diverse clinical
manifestations ranging from a mild, self-limiting state to variable
severity like acute respiratory distress syndrome (ARDS),
meningoencephalitis, acute kidney injury (AKI), myocardiatis leading to
heart failure, hepatitis and multi organ dysfunction (MOD). A late
presentation, delay in diagnosis and treatment causes overall 11.1%
deaths in children below 10 years because of low index of suspicion, and
non-specificity of signs and symptoms . Recently majority of the
cases in frequently occurring acute encephalitic syndrome (AES) / JE
outbreaks in Gorakhpur, Uttar Pradesh among children (<15 years), have
been reported to be due to scrub typhus [3,4]. Odisha is on the Eastern
Ghat and has been reporting seasonal AES outbreaks since 2009 at
specific interval ; but the etiology has not been established. On the
basis of the Gorakhpur report, when we did serological analysis of 30
AES archived samples collected from hospitalized children during the
2016 epidemic, we found that 23.3% (7/30) of the JE suspected cases were
positive for scrub typhus. This prompted us to carry out this pilot
study to investigate the burden of pediatric scrub typhus in this part
of the country.
This study was conducted from June to November 2017
among children attending OPD of health clinics situated in four
agro-climatic zones of the state. Patients below 15 years of age with
acute fever (>5 days) and suspected to be rickettsial infections were
included in the study. While patients diagnosed to have some other
associated infection were excluded. Data on clinical features and
demographics of each patient were collected and 1mL of venous blood
collected aseptically. Malaria, dengue and leptospira were screened by
rapid diagnostic kit (SD Standard Diagnostic Inc, South Korea) and
typhoid by Widal test. Diagnosis of scrub typhus was done based on test
result of IgM ELISA (In Bios International Inc., Seattle, WA). Subjects
having optical density of >0.5 at 450 nm were considered positive for
scrub typhus. Further diagnosis of scrub typhus was confirmed by PCR in
all cases having eschar, as described by Furuya, et al. . All
patients were treated by the local physician as per standard guidelines.
This study was approved by the Institutional Human Ethics Committee of
the ICMR-Regional Medical Research Centre, Bhubaneswar and State Ethics
Committee, Department of Health and Family Welfare, Government of Odisha.
Informed written consent for voluntary participation was taken from the
guardian/ parents of the children included in the study.
All statistical analyses were performed using SPSS
software version 16.0 (SPSS Inc., Chicago, IL). P value of 0.05 or less
was considered statistically significant.
During the study a total of 413 children [Mean (SD)
age, 5.4 (3.8)] with >5 days of acute fever were evaluated. Out of the
total samples analyzed, 201 (48.7%) were diagnosed to be positive for
scrub typhus by IgM ELISA, 16 (3.9%) for malaria (P. falciparum:
10; P. vivax: 6), 4 (0.97%) each for dengue and leptospira,
and 53 (12.8%) for typhoid. Out of 16 malaria positive cases, 6 (47.5%)
were found to be co-infected with scrub typhus. The diagnosis of scrub
typhus was further confirmed by PCR in 36 eschar samples. The study
showed a male preponderance (P=0.03) and 10.8 fold higher
incidence of scrub typhus infection in rural areas compared to urban
areas (Table I). Further, the number of suspected/
positive cases was observed to be more in the month of August to October
suggesting seasonality of transmission. The most important environmental
risk factors were living close to forests, bushes or crop fields, and
cattle shed as seen in 158 (78.6%) of positive patients (RR 11.6, P<0.001).
TABLE I Socio-demographic and Clinical Features of Scrub Typhus Positive Patients (N=201), June to November, 2017, Odisha
Age groups (y)
12 ( 6.0)
Fever >7 days
Puffiness of face
All of the 201 positive cases had a history of long
duration of fever ranging from 6-18 days with a median of 12 days. High
grade fever (>101ºF) was recorded in 177 (88.1%) children. Other common
symptoms/signs were cough (73.1%), myalgia (48.8%), headache (48.3%),
cervical lymphadenopathy (74.1%), puffiness of face (58.2%),
hepatosplenomegaly (33.3%), pedal oedema (21.4%) and maculopapular
rashes (19.4%). Eschar, which is an important pathognomonic sign, was
seen in 17.9% of cases (Web Fig. 1). The most common site
of eschar was inguinal region and axilla (33.2%) followed by back and
abdomen (16.7%), umbilicus (12.8% each), shoulder, hand, arm and
popliteal region (5.5% each) and genitalia (4.5%). Hematological
analysis revealed anemia (<11g/dL) in 109 (54.2%), thrombocytopenia
(platelets <150 x 109/L) in 43.9%, elevated ESR in 79.81%, and raised
liver enzymes in serum (AST in 81.8%, ALT in 73.3% and ALP in 56.1% of
Amongst the enrolled positive cases, 11 (5.5%)
children developed complications (ARDS 6; myocarditis 4; and
encephalopathy 1) and all recovered after appropriate treatment.
Doxycycline was used in 85.5% children and azithromycin in 14.5%.
In this study, 48.7% of the cases with acute febrile
illness in children <15 year was found to be due to scrub typhus and
around 5.5% of them developed systemic complications. High grade fever
(>101ºF) with cough,
cervical lymphadenopathy and puffiness of face were the most common
clinical features. Raised ESR and elevated liver enzymes were the most
important laboratory findings. However, the limitation of the study is
the sampling criteria, as the samples analyzed were only of suspected
So far pediatric scrub typhus has been reported from
21 states/union territories and those are mostly restricted to
complicated cases admitted to the hospital with pyrexia of unknown
origin (PUO) [7-11]. However, we have recruited pediatric patients
attending primary care hospitals with prolonged fever, where we have
confirmed that scrub typhus is an important cause of acute febrile
illness among children in this part of the country in rainy months
(August to October) conventionally the peak transmission season for
dengue, malaria, leptospira and other viral diseases exhibiting same
type of symptoms. Hence early identification of such co-infections is
crucial as their treatments differ drastically and also to avert
complications and mortality. A high index of clinical suspicion,
exploring the history of environmental exposure, and vigilant search for
the eschar are crucial for diagnosis as we have observed eschar in 17.9%
of cases, but absence of eschar does not rule out the diagnosis. In
spite of lack of community based data the increasing number of both
uncomplicated and complicated cases indicate that scrub typhus is a fast
emerging public health threat in the country and it needs targeted
preventive interventions like health education and personal protection
among the high risk groups . Additionally, sensitization of the
physicians at the PHC level hospitals should be done to use DHR–ICMR
guideline for diagnosis and management of the disease .
Acknowledgements: Mr M Barik, Mr KC Parichha, Mr
N Sahu and Mr HS Naik for assistance during field and laboratory
Contributors: MB,MR: conceived and executed the
study; MPM,SS,BD: examined the patients and collected the samples; MB:
conducted the laboratory tests; MR,MB: analyzed the data and drafted the
manuscript; SP: revised the manuscript. All authors read and approved
the final manuscript.
Funding: ICMR Intramural grant; Competing
interest: None stated.
What This Study Adds?
• Scrub typhus is an
important cause of acute febrile illness and acute encephalitic
syndrome among children in Odisha.
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