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Brief Reports Indian Pediatrics 2001; 38: 1393-1396 |
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Rickettsial Infections in South India – How to Spot the Spotted Fever
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The child with a rash and fever is all too often labeled as a case of "viral exanthematous illness" by pediatricians. This diagnosis may hold good in most cases and no active therapy is indicated. There are, however, several non-viral illnesses that present with a rash and fever, which are amenable to antimicrobial treatment; untreated, they are associated with significant morbidity and mortality. Rickettsial fever is one such entity seldom diagnosed in India, probably due to a low index of suspicion and the lack of diagnostic facilities in most laboratories. Earlier reports have documented the endemicity of rickettsioses among adults in the Himalayan belt, Maharashtra and Bangalore(1). There have been few reports of rickettsioses in children from the southern Indian states. Here we report children with rickettsial fever, in whom the diagnosis was aided by a characteristic skin rash involving the palms and soles. Subjects and Methods This study was carried out in children (both inpatients and outpatients) treated in a tertiary care hospital in Tamilnadu. The case records of children with a clinical diagnosis of rickettsial infection (fever, rash involving palms and soles) who tested positive for the Weil-Felix test were reviewed. Weil Felix test was done by the tube agglutination method. A titer of 1/160 or greater was considered significant(2). Results A clinical diagnosis of rickettsial infection was entertained in 57 children treated during the period between December 1996 and April 2000. Weil-Felix test was done in all. Tweleve children tested positive of whom nine were male and three female. The ages of the children ranged from 16 months to 12 years, with a median age of 4.7 years. Clinical features The clinical and laboratory features observed in the 12 children are summarized in Table I. Eleven children presented with a history of high grade and continuous fever. The duration of fever was less than one week in three children, one to two weeks in four children and more than two weeks in four. A history of tick bite was obtained in a single case. None of the children had pediculosis. All the children had a skin rash at diagnosis. The rash was generalized, predominatly on the peripheries and involved the palms and soles in all the children. Three children had a macular rash, two had a papular rash, three had a maculo-papular rash and four had a purpuric rash. The appearance of the rash was varied – on the second day of fever (5 children), third day (3 cases), fourth day (1 child), fourteenth day (1 child) or on the fifteenth day (1 child). Eight children had edema. Five children had pedal edema; one of them also had facial puffiness. Three had generalized edema. Five children presented with neurological manifestations. Three children had alteration of sensorium; two had seizures. Nine children had hepatosplenomegaly and three had only hepatomegaly. Arthralgia was seen in four children and two had abdominal pain. One girl developed pelvic ascites and hydrothorax during the course of the illness. Another child had pneumonia that developed on the tenth day of fever. Laboratory Investigations The diagnosis of rickettsial illness was made on the basis of a positive Weil Felix test in all the cases. Sera from four children were sent for confirmation to the Centre for Applied Microbiological Research (CAMR), Salisbury, U.K. Indirect Hemagglutination (IHA) test was done and spotted fever was confirmed in three children and typhus in one. The three children who had altered sensorium at admission had cerebrospinal fluid analyses. Two children had CSF white cell counts less than 100/ cu mm (20 and 7 cells / cu mm) and one had a CSF WBC count of 150 cells/ cu mm. All three children showed lymphocyte predominance. CSF glucose was normal in all; protein was normal in one patient and elevated in two. Treatment Seven of the 12 children were treated with chloramphenicol and two with tetracyline. Thre children did not return for the results of investigations. They received no treatment and were lost to follow up. Outcome In all nine children who were followed up, fever settled by a mean 3 days (range 2 to 6 days) of treatment. There were no deaths. Hepatosplenomegaly and edema had resolved by 14th day visit.
Table I__Clinical and Laboratory Features Observed
Discussion This case series documents that rickettsial infections are prevalent in south India and need to be considered among the differential diagnosis in children presenting with fever and rash. Specific serologic tests are necessary to confirm the diagnosis(3,4). In our series, of the four children tested with IHA, three were diagnosed to have spotted fever, while the fourth had typhus. As there are many species of rickettsiae, specific serologic testing may be difficult and expensive. Weil-Felix test is inexpensive and can be performed rapidly to substantiate the diagnosis. However, low sensitivity of Weil-Felix is a problem(5). Since the test is also a non-specific one, the result has to be carefully correlated with the clinical features to arrive at the diagnosis. The distribution of the rash and involve-ment of the palms and soles are important features that suggest the diagnosis of rickettsial fever(6). Additional features that may add to the clinical suspicion include edema of hands and feet, liver and/or spleen enlargement and arthralgia. The differential diagnoses to be considered in a child presenting with palmo-plantar rash are detailed in Table II. Among these diseases, the palmo-plantar rash due to scabies can be easily recognised clinically; a child with congenital syphilis may be diagnosed sero-logically and a child with Kawasaki disease should fulfill the diagnostic criteria. Thus having excluded these illnesses, rickettsial fever can be diagnosed clinically and substantiated by the Weil-Felix test. Rickettsial infections show prompt response to antimicrobial therapy. The drugs of choice in the treatment of rickettsial diseases are chloramphenicol (50-75 mg/ kg/day), tetracycline (25-50 mg/kg/day; in children older than 8 years) or fluoro-quinolones (ciprofloxacin 20-30 mg/kg/day) (7,8). Antibiotics should be continued until the patient has been afebrile for at least 24 hours or a minimum of 7 days. Delay in diagnosis and treatment may result in death or neurolgical sequelae(9).
Acknowledgement The authors wish to thank Dr. Graham Lloyd, CAMR, Salisbury, UK for his kind help in performing the IHA tests. Contributors: NM, SP, TL, VP and PR were involved in the care of the children, data collection and drafting of paper. TC will act as the guarantor for the paper. EM performed the laboratory tests. Funding: None. Competing interests: None stated.
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