Clinical profile and outcomes of pediatric scrub typhus associated with elevated hepatic transaminases.

BACKGROUND: Hepatic transaminase (HT) elevation is frequently seen in children with scrub typhus (ST), but the clinical implication of this common finding is not known. OBJECTIVE: To describe the clinical profile and outcome of pediatric ST with elevated hepatic transaminase. METHODS: In this prospective cohort study, all children < 12 years of age presenting with fever for ≥ 5 days and positive immunoglobulin M (IgM) serology for ST were included. Clinical findings, laboratory features and outcomes of children with elevated HT were compared with those who had normal HT. RESULTS: Of 560 ST positive children included, 257 (45.8%) had associated HT elevation. The common age group affected was 5 to 12 years of age (54.9%). Most of the children came during the second week of fever (68.5%) with mean duration of fever of 9.1 days. The common initial presenting symptoms were cough (77.8%), vomiting (65%) and myalgia (59.1%) and signs were hepatomegaly (64.2%), splenomegaly (57.6%) and generalized lymphadenopathy (54.1%). Eschar was seen in 49.8% of children. Thrombocytopenia (58%) and anemia (49%) were the frequently seen laboratory abnormalities. Severe forms of ST were seen in 45.5% children, of which pneumonia was most common. The fever clearance time (48 ± 19.2 h) and mean duration of hospital stay (6.7 ± 3.3 days) were prolonged in these children. On logistic regression analysis, generalized lymphadenopathy (p = 0.002), ascites (p = 0.037), thrombocytopenia (p < 0.001) and hypoalbuminemia (p = 0.023) were found to be associated with HT elevation in these children. CONCLUSIONS: Hepatic transaminase (HT) levels increase with the duration of untreated fever and is found to be associated with severe forms of scrub typhus. Children with elevated HT have delay in fever defervescence and their duration of hospital stay was prolonged.

Prospective Study to Assess the Response to Therapy and Its Predictors in Children with Scrub Typhus.

Doxycycline is the drug of choice for pediatric scrub typhus (ST) while azithromycin is considered as an equally effective alternative. This study was undertaken to assess the response to therapy and its predictors in pediatric ST cases treated with doxycycline and azithromycin. Children ≤12 year with fever ≥7 days were screened for ST by IgM ELISA (positive if optical density >0.5). All positive cases were divided into two groups based on whether treated with doxycycline or azithromycin. Fever clearance time (FCT), duration of hospitalization and other clinical characteristics of cases in both groups were compared. Out of 2710 children admitted with fever for more than 7 days, 660 cases (24.35%) tested positive for ST by IgM ELISA. Cases treated with azithromycin and doxycycline were 316 (47.87%) and 344 (52.12%), respectively. In our study, the FCT (p = 0.004), mean duration of hospital stay (p = 0.011), persistence of fever for >48 h after starting antibiotic therapy (p = 0.001) and severe ST requiring ICU admission (p = 0.046) were significantly lower in children who received doxycycline. The logistic regression analysis revealed that the presence of splenomegaly (Adjusted Odds Ratio (AOR) 2.60; 95% Confidence interval (CI) = 1.49-4.53; p = 0.001) and lung crepts (AOR 2.02; 95% CI = 1.06-3.85; p = 0.032) in azithromycin-treated group and presence of meningeal signs (AOR 16.11; 95% CI = 5.47-47.45; p < 0.001), anemia (AOR 2.28; 95% CI = 1.02-5.08; p = 0.044), lung crepts (AOR 2.66; 95% CI = 1.16-6.05; p = 0.020) and absence of eschar (AOR 3.48; 95% CI = 1.70-7.13; p = 0.001) in the doxycycline group was significantly associated with prolonged FCT (>48 h). Doxycycline is superior to azithromycin in defervescing fever, reducing hospital stay and preventing severity in pediatric ST.

Clinical profile and predictors of severity in paediatric scrub typhus with pulmonary involvement.

Pulmonary involvement is common in children with scrub typhus. Our paper outlines the clinical characteristics of pulmonary involvement and analyses the predictors of its severity. All scrub typhus serology-positive (optical density >0.5) children with pulmonary symptoms were included. Of 506 serology-positive scrub typhus cases, 256 (50.5%) had pulmonary symptoms, of whom 50 (9.8%) were severe. These severe cases were compared with non-severe cases. Interstitial pneumonitis was the commonest chest radiographic finding. Logistic regression analysis identified 'fever clearance time' >48 h, facial puffiness, maculopapular rash and anaemia to be significantly associated with severe pulmonary involvement.

Drug therapy in Pediatric Scrub Typhus - Is 'not Giving Azithromycin' a Risk Factor for PICU Admission?

NA.

Predictors of Severity in Pediatric Scrub Typhus.

OBJECTIVE: To identify the factors that can predict the severity of scrub typhus in children. METHODS: This prospective study was conducted at a tertiary care teaching hospital between November 2014 to October 2016. All children <12y of age admitted with fever for more than 7d and positive IgM ELISA for scrub typhus were included in the study. These children were followed during the hospital course and their laboratory results, response to treatment and complications were documented. Cases of 'severe scrub typhus' were identified based on criteria from published adult and pediatric studies. RESULTS: Out of 930 children with fever for more than 7d, IgM ELISA for scrub typhus was positive in 230 children. Ninety one (40.6%) cases fulfilled the criteria of 'severe scrub typhus' in children. Out of 45 factors, 27 potential factors were studied. The multivariate analysis identified 5 factors, breathlessness (OR: 6.85, 95%CI: 2.69 to 9.87), altered sensorium (OR: 11.48, 95% CI 3.43 to 10.19), leucocytosis (OR: 3.38, 95% CI 1.12 to 10.16), hypoalbuminemia (OR: 10.78, 95% CI 2.66 to 48.76), and hyponatremia (OR: 10.08, 95% CI 2.11 to 23.42) to be significantly associated with the 'severe scrub typhus' cases. CONCLUSIONS: Breathlessness, altered sensorium, leucocytosis, hypoalbuminemia, and hyponatremia predict severity in childhood scrub typhus. Presence of these factors should alert the treating physician regarding the need for intensive monitoring, treatment or referral.

Clinico - Laboratory Profile of Scrub Typhus - An Emerging Rickettsiosis in India.

OBJECTIVE: To study the clinical and laboratory profile of pediatric scrub typhus in rural south India. METHODS: This is a descriptive study of the clinical and laboratory features of 117 children with IgM ELISA proven scrub typhus out of 448 children, who were admitted in the Pediatric ward of a tertiary care hospital, during the study period of November 2014 through March 2015. RESULTS: Fever was present in all 117 children, with mean duration of fever at admission as 9 d. Gastrointestinal tract was the most commonly affected system, seen in 51 % of children. Cough (82 %), myalgia (70 %), vomiting (68 %), headache (45 %) and pain abdomen (42 %) were the most common symptoms of scrub typhus. Hepatomegaly (70), splenomegaly (53 %), pallor (50 %) and eschar (41 %) were the common clinical findings in children with scrub typhus. Out of 49 children with eschar, 32 were associated with regional lymphadenopathy, which was commonly seen in axillary, neck and groin regions. Leucocytosis (50 %), anemia (56 %), increased SGOT / SGPT (47 %), thrombocytopenia (41 %), hypoalbuminemia (40 %) and hyponatremia (40 %) were the common lab features. Shock (46 %), myocarditis (24 %) and pneumonia (16 %) were the common complications seen in these children. This study showed that early treatment for scrub typhus results in a good outcome in terms of early recovery and nil mortality. CONCLUSIONS: Regional lymphadenopathy is a marker of hidden or developing eschar. Total count and differential count should be interpreted on the background of the duration of fever. Since IgM ELISA, which is diagnostic of scrub typhus may not be widely available, any febrile child coming from rural area with hepatosplenomegaly, pallor, eschar, generalised / regional lymphadenopathy, anemia, leucocytosis, thrombocytopenia and increased Aspartate transaminase (AST) /Alanine aminotransferase (ALT) should be started on empirical Doxycycline or Azithromycin in order to prevent life threatening complications secondary to delay in therapy.