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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 56  |  Issue : 4  |  Page : 383-384

Splenic infarct secondary to scrub typhus: A rare association


Department of Internal Medicine, Max Super Speciality Hospital, New Delhi, India

Date of Submission17-Aug-2018
Date of Acceptance15-Feb-2019
Date of Web Publication30-Nov-2020

Correspondence Address:
Dr. S Kapoor
Department of Internal Medicine, Max Super Speciality Hospital, 1 Press Enclave Road, Saket, New Delhi–110 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9062.302044

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How to cite this article:
Kapoor S, Upreti R, Mahajan M. Splenic infarct secondary to scrub typhus: A rare association. J Vector Borne Dis 2019;56:383-4

How to cite this URL:
Kapoor S, Upreti R, Mahajan M. Splenic infarct secondary to scrub typhus: A rare association. J Vector Borne Dis [serial online] 2019 [cited 2021 Jan 21];56:383-4. Available from: https://www.jvbd.org/text.asp?2019/56/4/383/302044

Scrub typhus is a mite-borne illness caused by Orientia (formerly Rickettsia) tsutsugamushi, a gram negative bacillus. With an annual incidence of one million infections worldwide and around one billion in endemic areas[1], this disease can have multi-systemic involvement. However, splenic involvement is very rare and is only reported in a few autopsy studies[2]. Here in we report a rare case of splenic infarct in an 8-yr-old child, secondary to scrub typhus.

Case report

An 8-yr-old boy presented with complaint of high grade fever with chills and rigors since 10 days. For the last 3 days, he also had multiple episodes of non-projectile, non-bloody vomiting with vomitus containing food particles and mucus. On examination, the child looked dehydrated and was running with high grade fever (103.8 °F). He had tachycardia (PR-134/min), hypotension (BP- 80/60 mm Hg) with tenderness on left hypochondrium. The child was immediately given intravenous(I/V) boluses of ringer lactate. Meanwhile, basic blood tests were done and child was started on empirical I/V antibiotics.The blood reports revealed a low haemoglobin (Hb-13g/dl) and platelet (130 x 10[9]/l), normal total leucocyte count and deranged liver function (high aminotransferases) and borderline high creatinine (1 mg/ dl). Paired blood cultures, urine cultures also turned out to be sterile. Tests specific for malaria, dengue, chikungunya and typhoid were also found negative. An echocardiography was also done which showed no vegetations or any other abnormality. Chest X-ray also did not lead to the diagnosis.

As the child’s vitals stabilised with fluids and symptomatic management, he was re-examined and it revealed that there was an eschar on his medial aspect of right thigh. Based on this clinical finding, doxycycline was started and scrub typhus serology was ordered immediately. However, child’s tenderness in left hypochondrium was persistent. So, a non-contrast computed tomography of abdomen was performed which showed wedge-shaped area of hypointensity measuring 2.7 x 1.5 cm at the mid pole of spleen suggestive of an infarct [Figure 1]. Meanwhile, the positive scrub typhus serology confirmed the diagnosis. The child’s condition improved, his abdominal pain and fever subsided with oral doxycycline and was discharged in a stable condition after few days. This is a rare case of splenic infarct secondary to scrub typhus.
Figure 1: Spleen is mildly enlarged (12.5 cm) in size. A wedge-shaped area of hypodensity measuring 2.7 × 1.5 cm at the mid pole region suggestive of infarct.

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Caused by Orientia (formerly Rickettsia) tsutsuga- mushi, scrub typhus was first described in China in 313 AD. This disease if not timely diagnosed and treated, can lead to fatal illness due to multi-organ failure[3].

Gastrointestinal involvement is frequently reported in scrub typhus, most common being nausea, vomiting, diarrhoea, hematemesis and melena, which may be seen in one-fourth of patients[3]. On radiological examination one can find splenomegaly, peri-portal oedema, gall bladder walls thickening and intra-abdominal lymphadenopathy. Gastro-intestinal tract erosions and bleeding ulcers are frequently seen in upper gastrointestinal endoscopy[4]. However, splenic complications are extremely rare with only five cases of splenic infarct reported till now in literature[5],[6],[7],[8],[9].

The pathogenesis of this infarct can be attributed to focal or disseminated vasculitis, which is a result of either direct invasion of endothelial cells and phagocytes by the rickettsia or immune response by the body or more commonly a combination of both.Vasculitis is the major cause of all complications associated with scrub typhus. It can also explain the low platelet count in our patient who improved after initiation of treatment for scrub typhus. With timely initiation of treatment, complications can be very much prevented. In the present case as well, child’s left upper abdominal tenderness, which was secondary to splenic infarct completely subsided after giving doxycycline.

Thus, we conclude that although splenic infarct is a rare complication of scrub typhus, yet if a patient complains of left upper abdominal pain, it should be suspected and an early computed tomography must be done to rule it out.

Ethical statement

Written informed consent was obtained from the legal guardian of the patient for publication and no personal detailes or identity was divulged.

Conflict of interest

There are no conflict of interests to declare.

 
  References Top

1.
Raoult D. Scrub typhus. Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases. 6th edn. Philadelphia, PA: Elsevier Churchill Livingstone 2005; 2: 2309-10.  Back to cited text no. 1
    
2.
Settle EB, Pinkerton H, Corbett AJ. A pathologic study of tsut- sugamushi disease (scrub typhus) with notes on clinicopatho- logic correlation. J Lab Clin Med 1945; 30: 639-61.  Back to cited text no. 2
    
3.
Chrispal A, Boorugu H, Gopinath KG, Prakash JA, Chandy S, Abraham OC, et al. Scrub typhus: An unrecognized threat in South India — Clinical profile and predictors of mortality. Trop Doct 2010; 40(3): 129-33.  Back to cited text no. 3
    
4.
Kim SJ, Chung IK, Chung IS, Song DH, Park SH, Kim HS, et al. The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus. Endoscopy 2000; 32(12): 950-5.  Back to cited text no. 4
    
5.
Jung JO, Jeon G, Lee SS, Chung DR. Two cases of tsutsuga- mushi disease complicated with splenic infarction. Korean J Med 2004; 67 (Suppl 3): S932-6.  Back to cited text no. 5
    
6.
Raj SS, Krishnamoorthy A, Jagannati M, Abhilash KP. Splenic infarct due to scrub typhus. J Glob Infect Dis 2014; 6(2): 86-8.  Back to cited text no. 6
    
7.
Hwang JH, Lee CS. Incidentally discovered splenic infarction associated with scrub typhus. Am J Trop Med Hyg 2015; 93(3): 435.  Back to cited text no. 7
    
8.
Jeong YJ, Kim S, Wook YD, Lee JW, Kim KI, Lee SH. Scrub typhus: Clinical, pathologic, and imaging findings. Radiographics 2007; 27(1): 161-72.  Back to cited text no. 8
    
9.
Areum Durey, Hea Yoon Kwon,Young Kyoung Park, Ji Hyeon Baek, Seung Baik Han, Jae Seung Kang, Jin Soo Lee. A case of scrub typhus complicated with a splenic infarction. Infect Chemother 2018; 50(1): 55-8.  Back to cited text no. 9
    


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