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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 51-53

Scrub typhus in winters: A report of two cases from a tertiary care center in sub-himalayan region of the indian subcontinent


Department of Medicine, Dr. Rajendra Prasad Govt Medical College, Tanda, Himachal Pradesh, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Sujeet Raina
C-15, Type-V Quarters, Dr. RPGMC Campus, Tanda - 176 001, Kangra, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_94_17

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  Abstract 


In India, the geographic variation has been observed while reporting an outbreak of scrub typhus. Our country exhibits seasonality in scrub typhus outbreaks that coincides with the monsoon and postmonsoon period of June–October in Northern regions while it is autumn and early winter from September to January in Southern India. The occurrence of scrub typhus in winter months has not been reported from the sub-Himalayan region of the Indian subcontinent. We report two cases of scrub typhus diagnosed in December and February in a tertiary care center of Himachal Pradesh, India.

Keywords: Rickettsial diseases, winter, North India


How to cite this article:
Jain T, Parcha V, Raina S, Sharma R. Scrub typhus in winters: A report of two cases from a tertiary care center in sub-himalayan region of the indian subcontinent. CHRISMED J Health Res 2018;5:51-3

How to cite this URL:
Jain T, Parcha V, Raina S, Sharma R. Scrub typhus in winters: A report of two cases from a tertiary care center in sub-himalayan region of the indian subcontinent. CHRISMED J Health Res [serial online] 2018 [cited 2019 Oct 23];5:51-3. Available from: http://www.cjhr.org/text.asp?2018/5/1/51/223134




  Introduction Top


Scrub typhus is the most common Rickettsial infection in India. It is an acute febrile illness, caused by Orientia tsutsugamushi an obligate intracellular Gram-negative bacteria. It is transmitted to humans by the bite of infected larval mites or “chiggers” belonging to the family Trombiculidae.[1] Scrub typhus is affected by various meteorological factors which in turn affect the development, behavior, reproduction, and population patterns of the arthropods transmitting the infectious agent. In India, the disease has been reported from the majority of states.[2] The presence of scrub typhus has been well documented in Himachal Pradesh, situated in the western Himalayas.[3] The disease is seasonal in India and outbreaks correlate with the activity of larval mites. Infections are mostly reported during the rainy season and postrainy season. However, from South India, the highest numbers of cases are reported from September to January.[4] A PubMed search with MeSH words of “scrub typhus,” “winter months,” “North India,” and “Himachal Pradesh” did not find any items. We report two cases of scrub typhus diagnosed in December and February, respectively, in a tertiary care center of Himachal Pradesh, India. Both the patients belonged to the Chamba district of the state. This region has a variable climate of subtropical humid with dry winters to subalpine depending on altitude. We report these cases for the reason to make clinicians aware of winter type of scrub typhus and to consider in the differential diagnosis of acute undifferentiated fever in this region during winters also.


  Case Reports Top


Case 1

A 29-year-female patient was admitted in the 2nd week of February 2017 with a history of fever for the past 7 days. The fever was recorded up to 103°F and was associated with chills. History of progressive dyspnea was present for 5 days and orthopnea for the past 1 day. She had a history of a cough with mucoid expectoration for the past 5 days. Review of other systems was normal. No significant family and history was reported. The patient belonged to the area situated at an altitude of 1700 m above the mean sea level which receives snowfall during winter months. She denied leaving her place of residence during the last 3 weeks preceding the onset of symptoms. On examination, she was febrile, tachpyneic, and facial puffiness was present. An eschar was visible in the right groin region [Figure 1]a. Her pulse rate was 98/min; blood pressure was 100/70 mmHg; respiratory rate was 36/min, and saturation on room air was 90%. On chest auscultation, bilateral inspiratory crackles were heard. Examination of the abdomen demonstrated diffuse tenderness without guarding, rigidity and rebound tenderness. The abdomen was soft on palpation. Her hematology and biochemical investigations at admission are shown in [Table 1]. Her IgM ELISA for scrub typhus was positive (InBios International, Inc, USA). Her chest X-ray revealed bilateral infiltrates and the right costophrenic angle was obliterated. On ultrasound abdomen edematous gallbladder wall; mild splenomegaly (13.6 cm) and mild free-fluid were seen. She was started on doxycycline 100 mg twice a day. She became afebrile on the 3rd day after admission. She was discharged on day 8 with full recovery.
Figure 1: (a) Eschar in right inguinal region (b) Eschar in the right side of neck

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Table 1: Hemogram and biochemistry profile at admission

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Case 2

A 47-year-old female patient was admitted in the 1st week of December, 2016 with a history of fever for 8 days. The fever was recorded up to 103.5°F. Fever was associated with chills and headache. Review of other systems was normal. No significant family and history were reported. The patient belonged to the area situated at an altitude of 1200 m above the mean sea level, and the area encounters severe overnight and early morning frost without snowfall during winter months. She denied leaving her place of residence during the last 3 weeks preceding the onset of symptoms. On examination she was febrile. An eschar was visible on the right side of the neck [Figure 1]b. Rest of the general physical examination and systemic examination was normal. Her hematology and biochemistry investigations are shown in [Table 1]. Her IgM ELISA for scrub typhus was positive (InBios International, Inc, USA). She was started on doxycycline 100 mg twice a day and became afebrile within 48 h.


  Discussion Top


These are sporadic cases of scrub typhus which persists during the cooler winter months. Scrub typhus has a low probability in the differential diagnosis of acute undifferentiated fever during cooler winter months in the sub-Himalayan region of northern India. The index of suspicion is low during winters. With the clinical findings of typical eschar, the diagnosis is straightforward. However, nonspecific presentation and lack of pathognomonic eschar misdiagnoses and underreports scrub typhus during winter months.

The environmental milieu is conducive for the outbreaks of scrub typhus in monsoon and postmonsoon period of June–October in Northern regions and autumn to early winter from September to February in southern India. During this period abundant vegetation, temperature, rainfall, humidity, increases seasonal fluctuation of trombiculid mite, and subsequent exposures due to outdoor agricultural activity. Forest clearings, unplanned urbanization, deforestation, and rapid transport, jogging in parks, doing yoga, or any other recreational activities such as camping in the jungles have spread the disease to new foci.[2]

There are three possible reasons for people suffering from scrub typhus in winters. First, it is the species of chigger which can survive in winters. Second, unfed larva may be living beyond its longevity of 2 months. The chigger abundance during monsoon and postmonsoons may spill over to winters particularly in the setting of global warming and delayed ground freezing and gives chiggers an opportunity to feed on humans. Third, reservoir hosts for mite may be different for winter months.[5],[6]

In future studies will be undertaken to identify whether the bimodal pattern of occurrence – one in monsoon and postmonsoon and another in winters is present. In addition, clinical characteristics of patients with scrub typhus in winter and their comparison with the monsoon and postmonsoon variants will be a future study from this region.


  Conclusion Top


Clinicians should be alert about the possibility of scrub typhus in patients presenting with acute undifferentiated fever from this region. Initial failure to suspect scrub typhus might cause a diagnostic delay.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rahi M, Gupte MD, Bhargava A, Varghese GM, Arora R. DHR-ICMR guidelines for diagnosis & management of Rickettsial diseases in India. Indian J Med Res 2015;141:417-22.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Lascar AR, Suri S, Acharya AS. Scrub typhus: Re-emerging public health problem in India. J Commun Dis 2015;47:19-25.  Back to cited text no. 2
    
3.
Mahajan SK, Rolain JM, Kashyap R, Bakshi D, Sharma V, Prasher BS, et al. Scrub typhus in Himalayas. Emerg Infect Dis 2006;12:1590-2.  Back to cited text no. 3
[PUBMED]    
4.
Varghese GM, Raj D, Francis MR, Sarkar R, Trowbridge P, Muliyil J, et al. Epidemiology & risk factors of scrub typhus in South India. Indian J Med Res 2016;144:76-81.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Jeung YS, Kim CM, Yun NR, Kim SW, Han MA, Kim DM, et al. Effect of latitude and seasonal variation on scrub typhus, South Korea, 2001-2013. Am J Trop Med Hyg 2016;94:22-5.  Back to cited text no. 5
    
6.
Liu YX, Feng D, Suo JJ, Xing YB, Liu G, Liu LH, et al. Clinical characteristics of the autumn-winter type scrub typhus cases in South of Shandong province, Northern china. BMC Infect Dis 2009;9:82.  Back to cited text no. 6
[PUBMED]    


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