Case report of scrub typhus complicated by hypokalemia and multiple organ dysfunction syndrome

ABSTRACT CONTEXT: Scrub typhus, caused by Orientia tsutsugamushi, has a wide range of clinical manifestations, including meningoencephalitis, acute renal failure, pneumonitis, myocarditis, and septic shock. However, there are no documented cases of scrub typhus with hypokalemia. In this report, we present a case of scrub typhus with hypokalemia and multiple organ failure syndrome, highlighting the importance of electrolyte imbalance in patients with scrub typhus. CASE REPORT: A 59-year-old woman presented to the emergency department with abdominal pain that had been present for 1 day. On admission, the physical examination and laboratory test results indicated that the patient had renal, liver, and circulatory failure, and hypokalemia. She developed meningitis and disseminated intravascular coagulation during hospitalization. She recovered with appropriate management, and was discharged on day 17. CONCLUSION: This report highlights the potential for atypical presentations of scrub typhus, including a previously undocumented association with hypokalemia. Although the contribution of hypokalemia to the patient's clinical course remains uncertain, this case underscores the importance of considering electrolyte imbalance in the management of patients with scrub typhus. Further research is warranted to better understand the relationship between scrub typhus and electrolyte imbalance.

Research progress on the epidemiology of tsutsugamushi disease of summer type in China / 预防医学

@#Tsutsugamushi disease, also known as scrub typhus, is a zoonosis caused by Orientia tsutsugamushi, with rats as the main sources of infection and chigger mites as the only medium of transmission, and has no effective vaccines. Tsutsugamushi disease can be divided into summer, autumn and winter types according to seasons in China, while the summer type is characterized by strong virulence, typical and severe symptoms, high rates of misdiagnosis and mortality. The summer type of tsutsugamushi disease is distributed in the south of 31°N in China, with the epidemic time from June to August, and the cases are predominantly females, farmers and people at ages of over 40 years. Affected by natural environment, social and economic factors, the epidemic areas and the number of cases of summer type of tsutsugamushi disease are increasing continuously. Based on publications pertaining to the epidemiology of summer type of tsutsugamushi disease in China from 1960 to 2023, this review summarizes the mechanism of transmission, epidemiological characteristics and influencing factors, so as to provide the basis for prevention and control of summer type of tsutsugamushi disease in China.

Clinical characteristics of 38 cases of tsutsugamushi disease in Zaozhuang City, Shandong Province / 中华地方病学杂志

Objective:To understand the epidemiological and clinical characteristics of patients with tsutsugamushi disease in Zaozhuang City, Shandong Province, and to provide a basis for formulating effective diagnosis and treatment plan of tsutsugamushi disease. Methods:Retrospective analysis was carried out to collect clinical data of 38 patients with tsutsugamushi disease admitted to Zaozhuang Municipal Hospital of Shandong Province from 2018 to 2020. The epidemiological characteristics, clinical manifestations, laboratory examination results and drug treatment of patients with tsutsugamushi disease were analyzed. Results:Among the 38 patients with tsutsugamushi disease, 15 were males and 23 were females, aged (58.58 ± 14.47) years old; the occupation distribution was mainly farmers, accounting for 92.11% (35/38); the onset time was concentrated in October and November, accounting for 100.00% (38/38); the regional distribution was mainly in Yicheng District, accounting for 34.21% (13/38); 38 patients had a history of grassland/forest contact. All patients had fever, and other main symptoms were eschar (97.37%, 37/38), headache (68.42%, 26/38), fatigue (42.11%, 16/38), and whole body aches (36.84%, 14/38), etc. The results of laboratory examination mainly showed that C-reactive protein increased (89.47%, 34/38), procalcitonin increased (81.58%, 31/38), abnormal liver function (78.95%, 30/38), D-dimer increased (71.05%, 27/38), eosinophils decreased (60.53%, 23/38), and erythrocyte sedimentation rate increased (57.89%, 22/38). All 38 patients were cured after treated with doxycycline or azithromycin. Conclusions:The high incidence time of tsutsugamushi disease in Zaozhuang City is autumn. The clinical symptoms are mainly fever, eschar and headache. Doxycycline and azithromycin are the first choices for treatment of the disease.

A case of tsutsugamushi disease complicated by multiple organ dysfunction syndrome treated by extracorporeal membrane oxygenation / 中华危重病急救医学

Tsutsugamushi disease is an acute infectious disease caused by Rickettsia. Occasionally it has been reported in Macau, China. Critical cases are rare. Because the clinical manifestations of tsutsugamushi disease are non-specific and diverse, if not diagnosed and treated in time, the disease may progress to multiple organ dysfunction syndrome (MODS), severe acute respiratory distress syndrome (ARDS), and even death. A patient with tsutsugamushi disease complicated by MODS was admitted to the intensive care unit (ICU) of Kiang Wu Hospital in Macau, China on September 30, 2021. Combined with the history of outdoor activities (exposure to chigger mite larvae), clinical symptoms and signs (characteristic eschar of tsutsugamushi disease was found on the abdominal skin), related laboratory examinations (Weil-Felix test: negative). Diagnosis of tsutsugamushi disease with MODS. After admission, the patient was treated by anti-infection, correction of coagulation dysfunction, tracheal intubation and mechanical ventilation, noradrenalin to maintain blood pressure, continuous renal replacement therapy (CRRT), but the condition didn't improve significantly. We initiated veno-venous ECMO (VV-ECMO), which was initially setted blood flow to 5 L/min (70 mL·kg -1·min -1), rotate speed to 3 500 rpm, fractional concentration of inspired oxygen (FiO 2) to 1.00. Heparin was used as anticoagulant and activated coagulation time (ACT) was kept between 180 and 200 seconds. Meanwhile the speed of fluid removal in CRRT was adjusted. After 9 hours of ECMO support, the oxygenation improved, the blood flow of ECMO was reduced to about 4 L/min (58 mL·kg -1·min -1), rotate speed to 3 000 rpm. The patient's condition improved after 4 days of ECMO treatment and her ECMO flow rate and FiO 2 could be decreased gradually. On hospital day 5, ECMO was removed. Eight days on mechanical ventilation, the patient was successfully weaned and extubated. On day 11 of hospitalization, weaned the CRRT and turned to intermittent hemodialysis. The patient was transferred out of ICU due to her stable condition on the 12th day hospitalization. After that, her spontaneous urine output increased gradually. The functions of various organs returned to normal. After 36 days of hospitalization, she recovered and was discharged.

Predictive value of the C-reactive protein/albumin ratio in tsutsugamushi disease complicated with organ function damage / 中华急诊医学杂志

Objective:To explore the predictive value of the serum C-reactive protein (CRP)/albumin (ALB) ratio (CAR) for organ damage in tsutsugamushi disease.Methods:The clinical data of 166 patients with tsutsugamushi disease admitted to the First Affiliated Hospital of Wenzhou Medical University from January 1, 2010 to December 31, 2020 were retrospectively analyzed. The patients were divided into the organ damage group (72 cases) and non-organ damage group (94 cases) according to the organ damage criteria. The general data and laboratory test results of the two groups of patients were compared. The significant indicators of univariate analysis were analyzed by multivariate logistic regression analysis. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to analyze the predictive value of CAR for organ damage in patients with tsutsugamushi disease.Results:There were no significant differences in age, sex, days of fever, and admission body temperature between the organ damage group and non-organ damage group ( P>0.05). However, the body mass index, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ), sequential organ failure assessment (SOFA), length of hospital stay, hospitalization expense, percentage of neutrophils (NEUT), lymphocyte count, procalcitonin, CRP, and CAR in the organ damage group were significantly higher than those in the non-organ damage group ( P<0.05), and ALB was significantly lower than that in the non-organ damage group ( P<0.05). Multivariate logistic regression analysis showed that APACHEⅡ( P=0.039), NEUT ( P=0.003), and CAR ( P=0.011) were independent risk factors for tsutsugamushi disease complicated by organ damage. The ROC curve showed that the AUCs of APACHEⅡ, NEUT, and CAR were 0.655, 0.716, and 0.727, respectively. When the cut-off value of CAR was 2.86, the sensitivity was 55.6%, and the specificity was 79.8%. Conclusions:Elevated CAR is an independent risk factor for tsutsugamushi disease complicated with organ damage and can be used as an important indicator to evaluate the presence or absence of organ damage in patients with tsutsugamushi disease.

The importance of occupational history in clinical thinking from the diagnosis and treatment of a case of Tsutsugamushi disease / 中华劳动卫生职业病杂志

A farm worker in Baodi District of Tianjin was diagnosed with Tsutsugamushi disease due to fever and intermittent cough for more than 3 months.The patient's diagnosis and treatment process was complicated, and the diagnosis was delayed in the early stage of the disease because the clinician neglected the occupational history and lacked knowledge about the prevention and control of tsutsugamushi disease. As an important part of the epidemiological history, occupational history is crucial for the diagnosis of occupational related diseases. Clinical thinking runs through the whole process of clinical diagnosis and disease treatment, and correct clinical thinking can effectively reduce the occurrence of misdiagnosis.Clinicians should ask and record career history in detail to improve the quality of health care.

Feasibility of difference between hematocrit and albumin for identifying severity of scrub typhus disease / 中华危重病急救医学

Objective@#To explore the feasibility of difference between hematocrit and albumin (HCT-ALB) to evaluate the severity in patients with severe scrub typhus (Tsutsugamushi disease).@*Methods@#The clinical data of 408 patients with scrub typhus in 37 hospitals located in 15 prefectures of Yunnan Province from January 1st, 2017 to December 31st, 2018 were retrospectively collected. The patients were divided into the non-severe scrub typhus disease group (n = 265) and the severe scrub typhus disease group (n = 143) according to the diagnostic criteria. Volunteers attending Kunming City Medical Center in Yunnan Province for routine physical examination were enrolled as healthy control group (n = 230). HCT, ALB, lactate dehydrogenase (LDH), uric acid (UA), and acute physiology and chronic health evaluationsⅡ(APACHEⅡ) and sequential organ failure assessment (SOFA) within 24 hours after admission were collected. HCT-ALB difference was calculated. Pearson method was used to analyze the correlation between HCT-ALB difference and LDH, UA, APACHEⅡ and SOFA scores in patients with severe scrub typhus disease; the receiver operating characteristic (ROC) curve was used to analyze the value of HCT-ALB difference in the diagnosis of severe scrub typhus disease.@*Results@#① There was no significant difference in gender composition between patients with non-severe scrub typhus disease group and severe scrub typhus disease group, but the age of the severe scrub typhus disease group was significantly higher than that of the non-severe scrub typhus disease group (years old: 53.57±15.23 vs. 35.03±23.47, P < 0.01). ② Compared with the healthy control group, the HCT, ALB of the non-severe scrub typhus disease group and severe scrub typhus disease group were significantly decreased [HCT: (36.54±6.82)%, (38.13±7.60)% vs. (46.20±4.42)%; ALB (g/L): 35.53±5.87, 26.90±6.10 vs. 47.75±4.28, all P < 0.01], and the HCT-ALB difference was significantly increased (5.28±3.90, 11.26±6.62 vs. 1.55±5.32, both P < 0.01). Compared with the non-severe scrub typhus disease group, the HCT of the severe scrub typhus disease group was significantly increased [(38.13±7.60)% vs. (36.54±6.82)%, P < 0.01], the ALB was significantly decreased (g/L: 26.90±6.10 vs. 35.53±5.87, P < 0.01), and the HCT-ALB difference was significantly increased (11.26±6.62 vs. 5.28±3.90, P < 0.01). ③ Pearson correlation analysis showed that HCT-ALB difference was positively correlated with LDH and UA in patients with severe scrub typhus disease (r values were 0.316 and 0.284, respectively, both P < 0.01), and negatively correlated with APACHEⅡ score and SOFA score (r values were -0.229 and -0.198, respectively, both P < 0.05). ④ ROC curve analysis showed that the area under the curve (AUC) of HCT-ALB difference in the diagnosis of severe scrub typhus disease was 0.786, standard error was 0.024, P = 0.000, and 95% confidence interval (95%CI) was 0.739-0.832. When the best diagnostic value was 8.56, the sensitivity was 81.1%, the specificity was 60.8%, and the Youden index was 0.419.@*Conclusions@#HCT-ALB difference is an indicator to evaluate the severe scrub typhus disease. When HCT-ALB difference is above 8.56, it can be used as an indicator to identify severe scrub typhus disease.

Feasibility of difference between hematocrit and albumin for identifying severity of scrub typhus disease / 中华危重病急救医学

Objective To explore the feasibility of difference between hematocrit and albumin (HCT-ALB) to evaluate the severity in patients with severe scrub typhus (Tsutsugamushi disease). Methods The clinical data of 408 patients with scrub typhus in 37 hospitals located in 15 prefectures of Yunnan Province from January 1st, 2017 to December 31st, 2018 were retrospectively collected. The patients were divided into the non-severe scrub typhus disease group (n = 265) and the severe scrub typhus disease group (n = 143) according to the diagnostic criteria. Volunteers attending Kunming City Medical Center in Yunnan Province for routine physical examination were enrolled as healthy control group (n = 230). HCT, ALB, lactate dehydrogenase (LDH), uric acid (UA), and acute physiology and chronic health evaluationsⅡ(APACHEⅡ) and sequential organ failure assessment (SOFA) within 24 hours after admission were collected. HCT-ALB difference was calculated. Pearson method was used to analyze the correlation between HCT-ALB difference and LDH, UA, APACHEⅡ and SOFA scores in patients with severe scrub typhus disease; the receiver operating characteristic (ROC) curve was used to analyze the value of HCT-ALB difference in the diagnosis of severe scrub typhus disease. Results ① There was no significant difference in gender composition between patients with non-severe scrub typhus disease group and severe scrub typhus disease group, but the age of the severe scrub typhus disease group was significantly higher than that of the non-severe scrub typhus disease group (years old: 53.57±15.23 vs. 35.03±23.47, P < 0.01). ② Compared with the healthy control group, the HCT, ALB of the non-severe scrub typhus disease group and severe scrub typhus disease group were significantly decreased [HCT: (36.54±6.82)％, (38.13±7.60)％vs. (46.20±4.42)％; ALB (g/L): 35.53±5.87, 26.90±6.10 vs. 47.75±4.28, all P < 0.01], and the HCT-ALB difference was significantly increased (5.28±3.90, 11.26±6.62 vs. 1.55±5.32, both P < 0.01). Compared with the non-severe scrub typhus disease group, the HCT of the severe scrub typhus disease group was significantly increased [(38.13±7.60)％vs. (36.54±6.82)％, P < 0.01], the ALB was significantly decreased (g/L: 26.90±6.10 vs. 35.53±5.87, P < 0.01), and the HCT-ALB difference was significantly increased (11.26±6.62 vs. 5.28±3.90, P < 0.01). ③ Pearson correlation analysis showed that HCT-ALB difference was positively correlated with LDH and UA in patients with severe scrub typhus disease (r values were 0.316 and 0.284, respectively, both P < 0.01), and negatively correlated with APACHEⅡ score and SOFA score (r values were -0.229 and -0.198, respectively, both P < 0.05). ④ ROC curve analysis showed that the area under the curve (AUC) of HCT-ALB difference in the diagnosis of severe scrub typhus disease was 0.786, standard error was 0.024, P = 0.000, and 95％ confidence interval (95％CI) was 0.739-0.832. When the best diagnostic value was 8.56, the sensitivity was 81.1％, the specificity was 60.8％, and the Youden index was 0.419. Conclusions HCT-ALB difference is an indicator to evaluate the severe scrub typhus disease. When HCT-ALB difference is above 8.56, it can be used as an indicator to identify severe scrub typhus disease.

Analysis of the clinical characteristics of severe tsutsugamushi disease in Yunnan Province from 2017 to 2018 / 中华危重病急救医学

To analyze the clinical characteristics of severe tsutsugamushi disease, and to improve the ability of clinicians to recognize severe cases. Methods The clinical data of patients with tsutsugamushi disease from January 1st, 2017 to December 31st, 2018 in hospitals of Yunnan Province were retrospectively collected by the Case Report Form (CRF). The age, gender, clinical symptoms at admission; white blood cell (WBC), eosinophil count (EO), red blood cell (RBC), platelet count (PLT), hemoglobin (Hb), hematocrit (HCT), albumin (ALB), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), serum creatinine (SCr), uric acid (UA) on the first day of admission; and clinical outcomes were recorded. The patients were divided into the non-critical group and the critical group according to the diagnostic criteria, the data of clinical manifestation, laboratory examination, imaging examination and prognosis were compared between the two groups. Multivariate Logistic regression analysis was performed on the variables with statistical significance. The receiver operating characteristic (ROC) curve of LDH and UA for differential diagnosis of severe tsutsugamushi disease were drawn. Results From January 1st, 2017 to December 31st, 2018, 408 patients with tsutsugamushi disease were enrolled in 37 hospitals in 15 prefectures and municipalities of Yunnan Province. 385 cases were clinically diagnosed and 23 cases were laboratory diagnosed. There were 265 cases in non-critical group and 143 cases in critical group. A total of 8 cases died and the remaining 400 cases were discharged from hospital. ① Compared with the non-critical group, age of the critical group was older, the incidence of dizziness, cough, expectoration, general soreness, dyspnea, palpitation, abdominal pain, diarrhea, bulbar conjunctival congestion, pleural effusion, peritoneal effusion, pericardial effusion, hepatomegaly, splenomegaly, and the levels of WBC, ALT, AST, LDH, TBil, BUN, SCr, UA were significantly increased, the incidence of lymph node enlargement and the levels of EO, PLT and ALB were significantly decreased, and there was no significant difference in other indicators between the two groups.② Multivariate Logistic regression analysis showed that age, dyspnea, palpitations, LDH, UA, ALB were risk factors for severe tsutsugamushi disease, βvalue was 0.040,-2.147,-1.414, 0.002, 0.005 and-0.132 respectively, and the odds ratio (OR) was 1.041, 0.117, 0.243, 1.002, 1.005 and 0.877 respectively (all P < 0.01). ③ROC curve analysis showed that UA and LDH had better accuracy in differential diagnosis of severe tsutsugamushi disease (both P < 0.01), and the area under ROC curve (AUC) was 0.693 [95% confidence interval (95%CI) = 0.633-0.754], 0.819 (95%CI = 0.776-0.862), respectively. When the cut-off of UA was 306.2 μmol/L, the sensitivity was 60.8%, and the specificity was 77.4%. When the cut-off of LDH was 485.5 U/L, the sensitivity was 74.8%, and the specificity was 74.7%. The diagnostic value of UA combined with LDH was higher, AUC was 0.832, the sensitivity was 69.9%, and the specificity was 85.3%. Conclusion Severe tsutsugamushi disease can be diagnosed at an early stage according to age, respiratory distress, palpitations, hypoalbuminemia, UA >306.2 μmol/L, and LDH > 485.5 U/L.

Diagnostic value of combined measurement of serum procalcitonin and β2 microglobulin in tsutsugamushi disease / 中华地方病学杂志

Objective To explore the diagnostic values of combined detection of serum procalcitonin (PCT) and β2 microglobulin (β2MG) in tsutsugamushi disease.Methods Serum PCT and β2MG were compared in cases of tsutsugamushi disease and fever patients at the same time,who were hospitalized at Fourth Affiliated Hospital of Guangxi Medical University from June 2014 to May 2017.The best diagnosis cut-off value of tsutsugamushi disease was calculated by receiver operating characteristic (ROC) curve.Results A total of 57 cases of tsutsugamushi disease,40 cases of sepsis,17 cases of acquired immunodeficiency syndrome (AIDS),17 cases of severe community-acquired pneumonia (SCAP),63 cases of common community-acquired pneumonia (CCAP),14 cases of pulmonary tuberculosis (PTB),20 cases of upper respiratory tract infection,13 cases of other infectious fever and 28 cases of non-infectious fever patients were selected.The level of serum PCT in tsutsugamushi disease [0.87 (0.68-1.34) μg/L] was higher than those in AIDS [0.47 (0.20-1.12) μg/L],CCAP [0.17 (0.09-0.51) μg/L],PTB [0.13 (0.05-0.18) μg/L],upper respiratory tract infection [0.23 (0.05-0.48) μg/L] and non-infectious fever [0.09 (0.06-0.13) μg/L],but was lower than those in sepsis [5.00 (1.04-18.78) μg/L] and SCAP [3.35 (0.76-14.41) p,g/L,P ＜ 0.05],while the difference was not significant compared with other infectious fever [0.76 (0.13-1.99) μg/L,P ＞ 0.05].The level of serum β2MG in tsutsugamushi disease [(5.67 (4.47-7.90) mg/L] was higher than those in sepsis [2.83 (2.10-4.54) mg/L],AIDS [3.85 (3.19-5.22) mg/L],SCAP [3.83 (2.98-5.58) mg/L],CCAP [1.99 (1.51-2.75) mg/L],PTB [1.92 (1.37-3.00) mg/L],upper respiratory tract infection [2.02 (1.25-2.74) mg/L],other infectious fever [2.45 (1.51-4.12) mg/L] and non-infectious fever [2.99 (2.06-4.30) mg/L,P ＜ 0.05].ROC curve showed that the most suitable diagnosis cut-off value of serum PCT in tsutsugamushi disease was 0.53 μg/L,the sensitivity was 94.7％,and the specificity was 60.4％.The critical value of serum β2MG was 3.74 mg/L in diagnosis of tsutsugamushi disease,its corresponding sensitivity and specificity were 91.2％ and 75.9％,respectively.The sensitivity and specificity of combined serum PCT and β2MG in diagnosis of tsutsugamushi disease was 87.7％ and 86.3％,respectively.Conclusion Combined detection with serum PCT and β2MG can improve early diagnosis of tsutsugamushi disease.

Mathematical Modeling for Scrub Typhus and Its Implications for Disease Control

BACKGROUND: The incidence rate of scrub typhus has been increasing in the Republic of Korea. Previous studies have suggested that this trend may have resulted from the effects of climate change on the transmission dynamics among vectors and hosts, but a clear explanation of the process is still lacking. In this study, we applied mathematical models to explore the potential factors that influence the epidemiology of tsutsugamushi disease. METHODS: We developed mathematical models of ordinary differential equations including human, rodent and mite groups. Two models, including simple and complex models, were developed, and all parameters employed in the models were adopted from previous articles that represent epidemiological situations in the Republic of Korea. RESULTS: The simulation results showed that the force of infection at the equilibrium state under the simple model was 0.236 (per 100,000 person-months), and that in the complex model was 26.796 (per 100,000 person-months). Sensitivity analyses indicated that the most influential parameters were rodent and mite populations and contact rate between them for the simple model, and trans-ovarian transmission for the complex model. In both models, contact rate between humans and mites is more influential than morality rate of rodent and mite group. CONCLUSION: The results indicate that the effect of controlling either rodents or mites could be limited, and reducing the contact rate between humans and mites is more practical and effective strategy. However, the current level of control would be insufficient relative to the growing mite population.

Diagnosis and treatment of 38 cases of tsutsugamushi disease / 中国生化药物杂志

Objective To deepen the understanding of the clinical features of tsutsugamushi disease, in order to improve the diagnosis and treatment level. Methods The clinical data of 38 patients with tsutsugamushi disease were analyzed retrospectively in Shengzhou People 's Hospital from June 2015 to October 2016. Results All patients had persistent fever, were found eschar; 5 cases of elevated white blood cells, decreased in 10 cases, 23 cases of normal, C-reactive protein increased in 32 cases, 19 cases of thrombocytopenia, alanine aminotransferase increased in 29 cases, 22 cases of serum sodium, 19 cases of hypokalemia, 38 cases of serum albumin decreased; 26 cases of rash, 23 cases of pneumonia, inguinal lymph nodes in 22 cases, complicated by septic shock, respiratory failure in 3 cases. Conclusion The clinical symptoms of tsutsugamushi disease are diverse and lack of specificity. In patients with persistent fever in summer and autumn, it is necessary to guard against tsutsugamushi, and the eschar is found in time. The diagnosis and treatment is reduced and the misdiagnosis rate is reduced.

Diagnosis and treatment of 38 cases of tsutsugamushi disease / 中国生化药物杂志

Objective To deepen the understanding of the clinical features of tsutsugamushi disease, in order to improve the diagnosis and treatment level. Methods The clinical data of 38 patients with tsutsugamushi disease were analyzed retrospectively in Shengzhou People 's Hospital from June 2015 to October 2016. Results All patients had persistent fever, were found eschar; 5 cases of elevated white blood cells, decreased in 10 cases, 23 cases of normal, C-reactive protein increased in 32 cases, 19 cases of thrombocytopenia, alanine aminotransferase increased in 29 cases, 22 cases of serum sodium, 19 cases of hypokalemia, 38 cases of serum albumin decreased; 26 cases of rash, 23 cases of pneumonia, inguinal lymph nodes in 22 cases, complicated by septic shock, respiratory failure in 3 cases. Conclusion The clinical symptoms of tsutsugamushi disease are diverse and lack of specificity. In patients with persistent fever in summer and autumn, it is necessary to guard against tsutsugamushi, and the eschar is found in time. The diagnosis and treatment is reduced and the misdiagnosis rate is reduced.

Progress of diagnosis and treatment of tsutsugamushi disease / 中华实用儿科临床杂志

Tsutsugamushi disease is an acute infectious disease caused by Rickettsia tsutsugamushi.The clinical symptoms of tsutsugamushi disease are varied and non-specific,such as sudden onset fever with chills,rash,skin eschar of ulcer,lymphadenectasis,et al.Patients could combine with multi-organ dysfunction,include respiratory failure,heart failure,mild renal or hepatic dysfunction,circulatory shock or hematological abnormalities.Since the symptoms and signs are non-specific and resemble other tropical infections like malaria,enteric fever,dengue or leptospirosis,appropriate laboratory tests are necessary to confirm diagnosis,and reduce misdiagnosis and missed diagnosis rate.The mainstay of treatment is the tetracycline,chloramphenicol,macrolide and quinolone group of antibiotics.In mild cases,recovery is complete.In severe cases with multi-organ failure,mortality may be as high as 24％.Improve the early diagnosis and timely treatment of the disease,for improving the prognosis of patients,reduce the disease burden is of great significance.

Analysis of the clinical data from 56 misdiagnosis patients with Tsutsugamushi / 中国基层医药

Objective To improve the understanding of the epidemiology,clinical features,diagnosis and treatment of Tsutsugamushi disease,and reduce the misdiagnosis rate.Methods The clinical data of 56 cases of Tsutsugamushi disease misdiagnosed were analyzed retrospectively.Results 28 cases were misdiagnosed as acute upper respiratory tract infection(50.0%),3 cases were malaria(5.4%),1 case was cholecystitis(1.8%),24 cases were infectious fever(42.8%).The average misdiagnosed time:10.3days.55 patients were found Eschar or ulcer (98.2%),54 cases were found Eschar or ulcer on one part of body,1 case was found two eschars.54 cases had been effectively treated,50 cases were treated with chloramphenicol,4 cases with azithromycin.The average time of temper-ature that dropped to normal were respectively:1.3d,1d.Conclusion awareness of Tsutsugamushi disease should be raised,history seriously should be inquired and specific signs should be identified,which can degrade the misdiagnosis rate and reduce the mortality rate.

Tsutsugamushi Disease and Acute Bilateral Hearing Loss / 대한피부과학회지

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. The main symptoms of scrub typhus are fever, eschar, generalized rash, and swelling of the lymph nodes. Complications include pneumonia, myocarditis, meningitis, hepatitis, acute renal failure, and hearing loss. We report a rare case of Tsutsugamushi disease with acute bilateral hearing loss in a 65-year-old woman. The antibodies against O. tsutsugamushi were detected which led to the diagnosis of scrub typhus. She was treated immediately with oral doxycycline for 9 days and had a rapid and complete recovery. Scrub typhus can be associated with hearing loss, which is present in approximately one-third of the cases, but it is rare in Korea, therefore it is easy to misdiagnose scrub typhus as any other otological abnormalities. When patients present with fever, rash, and sensorineural hearing loss, clinicians should suspect scrub typhus and consider empirical antibiotic therapy.

A Comparison of Clinical Manifestations of Patients with Tsutsugamushi Disease between Children and Adults / 소아감염

PURPOSE: We compared the clinical manifestations of patients with tsutsugamushi disease between children and adults. METHODS: From January 2003 to December 2012, 768 patients diagnosed with tsutsugamushi disease were retrospectively reviewed, and the clinical characteristics, laboratory findings, and complications were compared between children and adults. RESULTS: No patterns of annual increases in the number of patients were noted in both children and adults. The higher incidences occurred in October and November respectively. By gender, male outnumbered female in children, but the opposite trend was seen in adults. By residential area, the urban distribution of children was higher than that of adults. Rashes (P=0.001) and eschar (P=0.004) were more common in children, while myalgia was more common in adults. Children had a high prevalence of anemia (P=0.041), and low incidence rates of thrombocytopenia, abnormal liver and renal function. Children yielded better results in the duration of their hospital stay and the incidence of complications (P<0.001). A comparison of the therapeutic effects of doxycycline and macrolide antibiotics, which was performed only on the children, did not reveal any significant differences. CONCLUSION: Compared to adults, children had higher incidence rates of male patients and more often suffered from rashes and eschar. Children yielded better results in the laboratory findings and duration of the hospital stay and complications. Therefore, when children are suspected to have tsutsugamushi disease, especially during its peak occurrence period, detailed physical examination and serological test should be performed to ensure a prompt diagnosis, and the use of macrolide antibiotics, which have fewer side effects, is expected to yield the same therapeutic effects.

ANCA-associated Vasculitis after Scrub Typhus

Anti-neutrophilic cytoplasmic antibody (ANCA)-associated vasculitis is a primary systemic vasculitis that affects the small vessels, and ANCA is involved as the common pathogenesis. Environmental factors such as infectious agents have been considered to play a role in triggering the autoimmunity. We report here on a case of ANCA-associated vasculitis that developed after scrub typhus. A 64-year-old male was admitted because of fever, chills, pain, weakness and hypoesthesia of his calves. He was diagnosed as having scrub typhus based on the findings of an eschar and the positive serum anti-orientia antibody. The fever continued despite the antibiotic treatment. Neurologic symptoms such as numbness, hypoesthesia and weakness began to develop in the hands, feet and calves with a persisting fever. The nerve conduction velocity study revealed mononeuritis multiplex of the superficial peroneal nerve and the median nerve. Microscopic hematuria then additionally developed, and the serology showed a positive myeloperoxidase (MPO) test. A nerve biopsy was conducted on the left superficial peroneal nerve and the result showed non-infectious systemic vasculitis of the medium-small arteries. He was diagnosed as having microscopic polyangiitis along with ANCA associated vasculitis. The fever resolved and the neurologic symptoms began to improve after steroid pulse treatment (methylprednisolone 1 g/day). The neuropathy gradually improved after discharge. We presume that the ANCA-associated vasculitis was triggered by scrub typhus.

Case of Tsutsugamushi Disease With Anterior Uveitis

PURPOSE: To report a single case of tsutsugamushi disease with anterior uveitis and eschars on the upper eyelid. CASE SUMMARY: A 56-year-old female patient complained of ocular pain and gradually decreasing visual acuity in her right eye. On physical examination, lymphadenopathy was palpable on the right side of the neck, and eschars were observed on the forehead and upper eyelid. On slit lamp examination, conjunctival injection, episcleral vessel dilations and severe intraocular inflammatory reaction were observed. Fundus examination showed no abnormal findings. A blood test was submitted for analysis, and tsutsugamushi disease was diagnosed. The patient's ocular manifestations responded well to treatment with steroids. After three weeks, the patient showed improvement on ocular examination, and no problems were observed at the six-month follow-up. CONCLUSIONS: Although ocular manifestation of tsutusgamushi disease with conjunctivitis and limbitis has previously been reported, ocular manifestation of tsutusgamushi disease with anterior uveitis has not been reported. Anterior uveitis may respond satisfactorily to steroid treatment, along with improvement in systemic conditions.

A Case of Tsutsugamushi Disease Associated With Intermediate Uveitis and Retinal Detachment

PURPOSE: The authors report a Tsutsugamushi patient who has intermediate uveitis and rhegmatogenous retinal detachment without a typical skin eschar, which may be rare. CASE SUMMARY: The authors present a case of a 63-year-old man who complained of fever, chills, and headache, with lymphadenopathy, hepatomegaly, reticulonodular pneumonia, and blurred vision in the right eye after descending a mountain in autumn. Serological findings showed elevated titers for strains of Rickettsia tsutsugamushi, even though no eschar could be found on his body. In addition, the ophthalmologic examination disclosed vitreous opacity as uveitis in his right eye; thus, the patient was treated for Tsutsugamushi disease. However, retinal detachment was found in his right eye even after treatment. Thus, a vitrectomy and intravitreal silicone oil injection was performed, and the patient's best corrected visual acuity improved from hand motion to 0.04 on the 7th day after the operation.