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Indian Pediatr 2011;48: 991 |
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Persistent Thrombocytopenia Due to Scrub
Typhus |
K Jagadish Kumar and VG Manjunath
Department of Pediatrics, JSS Medical College, JSS
University, Mysore, Karnataka, India.
Email: [email protected]
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A 5 year old girl presented with fever for 7 days with no history of
myalgia, joint pains, gastro-intestinal symptoms and bleeding tendencies.
She was sick, febrile (102ºF), tachypneic (RR-52/min), and had
a pulse rate of 124/min and BP of 100/68 mm Hg. She had conjunctival
suffusion but no lymphadenopathy, rash or eshcar. Systemic examination was
unremarkable except for hepatomegaly of 3 cm and spleen of 1cm. Laboratory
tests were as follows: Hb 11g/dL, TLC 4. 6 ×10 3/mL with
normal differential count, platelets 21×103/mL, ESR 50 mm and
haematocrit 30%. Other investigations revealed SGOT 201 U/L, SGPT 124 U/L
and blood sugar 88 mg/dL. Blood urea, creatinine, electrolytes, total
proteins and albumin levels were normal. Chest X-ray, ultrasound
abdomen and thorax were also normal. In view of conjuctival suffusion,
tachypnea and thrombocytopenia, a differential diagnosis of dengue,
leptospirosis and typhoid was made. Child received IV fluids, oxygen and
parentenal ceftriaxone. Her blood and urine culture was sterile. Serology
for typhoid, leptospira, dengue and QBC for malarial parasite were
negative. She remained febrile even after 6 days of IV ceftriaxone and her
platelets remained persistently below 50×103/mL. Her HIV,
Weil-Felix, Paul Bunnel and Brucella tests were negative but
immunochromatography test (both IgM and IgG) for scrub typhus was
positive. She received oral doxycycline and became afebrile in next 36
hours. Her platelets rose to 96×103/mL by 4th day and 360×103/mL
by 8th day and she was discharged.
Scrub Typhus is caused by Orientia tsutsugamushi
and very few reports are available in children from India [1,2]. The case
fatality in untreated may be as high as 10% [2]. Out of 5 children, none
had rash or eschar in a report from India, and typical rash and eschar may
not be always present [1,2]. In another study from Thailand 7 out of 73
children with scrub typhus only 7% had skin rash and eschar and only 19%
had thrombocytopenia [3]. Distinguishing scrub typhus from other acute
febrile thrombocytopenic illnesses like enteric fever, malaria, dengue in
tropical countries is usually difficult. In malaria, associated anemia in
a non toxic child gives clue. In enteric fever, GIT symptoms in a toxic
child with leucopenia and eosinopenia will help. Dengue will have
characteristic rash, retro-orbital pain, myalgia, bleeding tendencies with
increased haematocrit and raised liver enzymes. Watt, et al. [4]
noticed that hemorrhagic manifestations, low platelet count (<140,000/mm 3)
and low WBC count (<5,000/mm3) were strongly associated with
dengue when compared to Scrub typhus in adults [4]. Our child also had low
WBC count (4600/mm3), severe thormbocytopenia (21000/mm3),
raised liver enzymes similar to dengue. Therefore a high index of
suspicion is important as scrub typhus is treatable with easily available
antibiotics.
References
1. Mahajan SK, Rolain JM, Sankhyan N, Kaushal RK,
Raoult D. Pediatric scrub typhus in Indian Himalayas. Indian J Pediatr.
2008;75:947-9.
2. Pavithran S, Mathai E, Moses PD. Scrub typhus.
Indian Pediatr. 2004:41;1254-7.
3. Silpapojakul K, Varachit B, Silpapojaku K.
Paediatric scrub typhus in Thailand: a study of 73 confirmed cases. Trans
Royal Soc Trop Med Hyg. 2004:98;354-9.
4. Watt G, Jongsakul K, Chouriyagune C, Paris R.
Differentiating dengue virus infection from scrub typhus in Thai adults
with fever. Am J Trop Med Hyg. 2007:76;801-5.
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