Abstract: Scrub Typhus, or tsutsugamushi disease is a febrile illness caused by bacteria of the family Rickettsiaceae and named Orientia tsutsugamushi. Recently it has been found to endemic in Subhimalayan region of India. Scrub typhus affects skeletal muscles, skin, lungs, kidneys, brain and cardiac muscles.We report a rare case of scrub typhus presenting as acute myocardial infarction.
Keywords: Scrub typhus; Myocardial infarction
Case Report
A 42 year old male presented with history of fever of 5 days duration , fever was high grade documented around 1030 F , associated with severe bodyaches and chest pain, which was retrosternal , squeezing, associated with sweating, palpitations and radiating to left side of shoulder since 6 hours. There was no history of any yellowish discoloration of eyes, decreased urine output, headache & altered sensorium.
On examination patient wasconscious, cooperative, tachypneic, tachycardia was there, perspiring and patient continued to have chest pain, blood pressure was 128/76mmHg, febrile ,there was conjuctival suffusion and insignificant axillary lymphadenopathy. Eschar was present over the scrotum. Rest of the systemic examination was normal.
Electrocardiography was done in the casuality and it was showing ST elevation in V1-V6 region and Trop T was positive. Kidney & Liver function tests were within normal range, blood & urine cultures were sterile. No history and risk factors suggesting towards young CAD and work up for the same was within normal limit. Bedside Echocardiography was done to rule out myocarditis, but it was showing regional wall motion abnormality in LAD territory. In view of epidemicity of scrub typhus in sub-himalayan regions IgMELISA for scrub typhus was done & was showing positivity for scrub typhus.
Managed with streptokinase 1.5 million units after premedication, Aspirin 325mg stat, Clopidogrel 600mg stat, High dose of atorvastatin 80mg, Metoprolol 12.5mg 6 th hourly, Low moleculer weight heparin 0.6 ml 1BD & Injectable Azithromycin 500 mg IV once a day for 3 days & Doxycycline 100 mg twice a day for 14 days.At discharge patient was pain free, fully conscious, was able to communicate with his attendents & was able to walk individually and adviced regarding the exercise, diet and anti –ischemic drugs and adviced to come after 2 weeks .
Discussion
Increased prevalence of scrub typhus has been noted in the asian subcontinents and tsutsugaushi triangle.Scrub thypus is a common infection in sub Himalayan region of India1 and it is known to occur all over India, including Southern India.2 Scrub typhus is a small obligate gram negative, intracellular bacteria, Family rickettsiae, genus orientiae & its Cell wall lacks peptidoglycans and lipopolysaccharides. Primary reserviour, is a chigger/mite, larval stage,trombiculid mite (Leptotrombium daliense and others). Secondary reserviours are mainly rodents & humans. Incubation period is 5-20 days, mean 10-12 days.
Orientia tsutsugamushi is the causative agent & transmitted tohumans through the bite of thrombiculid mites. The mites have a four-stage lifecycle: egg, larva, nymph and adult. It is the accidental disease in humans & chigger (larval) phase is the only stage that is parasitic on animals or humans.3 It divides and breeds within the phagocytes and escape from the cell back into the circulation to continue to proliferate on the endothelium of small blood vessels releasing cytokines which damage endothelial integrity, causing fluid leakage, platelet aggregation, polymorphs and monocyte proliferation, leading to focal occlusive end -angiitis causing microinfarcts.
It is now well established that a majority of sequelae associated with human rickettsioses are the outcome of‘Rickettsial vasculitis’. 4 Especially affects skeletal muscles, skin, lungs, kidneys, brain and cardiac muscles. Cardiovascular system manifestations are mainly due to endothelial cell damage, vasculitis , inflammatory cell infiltration, typhus nodules, new endothelial cell proliferation, thrombosis, ischemia & infarction.4,5 Till now only one case was reported in english literature “acute myocardial infarction following scrub typhus infection”. 6
Severe infections may be complicated by interstitial pneumonia, pulmonary edema, congestive heart failure, circulatory collapse, and a wide array of signs and symptoms of central nervous system dysfunction, including delirium, confusion, and seizures. Death may occur as a result of these complications, usually late in the second week of the illness.
Learning Points
The importance of this case report is too highlight that scrub typhus can cause vasculitis of organ system in the body especially lungs, kidney, brain & cardiac tissue.
References
1. Sharma A, Mahajan S, Gupta ML, Kanga A and Sharma V. Investigation of an Outbreak of Scrub Typhus in the Himalayan Region of India. Jpn J Infect Dis. 2005;58:208 -210
2 . Mathai E, Lloyd G, Cherian E et al. Serological evidence for the continued presence of human rickettsioses in southern India. Annals of Tropical Medicine and Parasitology 2001;95:395 -398.
3 . James MT. Mites and mite -borne disease. In: Harwood RF, ed, Medical Entomology. 6th ed. New York: Macmillan, 1969; 379 -87.
4 . Settle EB, Pinkerton H, Corbett AJ. A pathologic study of tsutsugamushi disease with notes on clinicopathologic correlation. J Lab Clin Med 1945;30:639 -661.
5 . Allen AC, Saitz S. A comparative study of the pathology of scrub typhus( tsutsugamushi disease) and other rickettsial disease. Am J Pathol 1945;21: 6 0 3
6 . Kim DG, Kim JW, Choi YS, Kim SH, Kim SM, Park CG, Seo HS, Oh DJ. Acute myocardial infarction following scrub typhus infection. Int J Cardiol. 2007 Dec 15;123(1):73.
Keywords: Scrub typhus; Myocardial infarction
Case Report
A 42 year old male presented with history of fever of 5 days duration , fever was high grade documented around 1030 F , associated with severe bodyaches and chest pain, which was retrosternal , squeezing, associated with sweating, palpitations and radiating to left side of shoulder since 6 hours. There was no history of any yellowish discoloration of eyes, decreased urine output, headache & altered sensorium.
On examination patient wasconscious, cooperative, tachypneic, tachycardia was there, perspiring and patient continued to have chest pain, blood pressure was 128/76mmHg, febrile ,there was conjuctival suffusion and insignificant axillary lymphadenopathy. Eschar was present over the scrotum. Rest of the systemic examination was normal.
Electrocardiography was done in the casuality and it was showing ST elevation in V1-V6 region and Trop T was positive. Kidney & Liver function tests were within normal range, blood & urine cultures were sterile. No history and risk factors suggesting towards young CAD and work up for the same was within normal limit. Bedside Echocardiography was done to rule out myocarditis, but it was showing regional wall motion abnormality in LAD territory. In view of epidemicity of scrub typhus in sub-himalayan regions IgMELISA for scrub typhus was done & was showing positivity for scrub typhus.
Managed with streptokinase 1.5 million units after premedication, Aspirin 325mg stat, Clopidogrel 600mg stat, High dose of atorvastatin 80mg, Metoprolol 12.5mg 6 th hourly, Low moleculer weight heparin 0.6 ml 1BD & Injectable Azithromycin 500 mg IV once a day for 3 days & Doxycycline 100 mg twice a day for 14 days.At discharge patient was pain free, fully conscious, was able to communicate with his attendents & was able to walk individually and adviced regarding the exercise, diet and anti –ischemic drugs and adviced to come after 2 weeks .
Discussion
Increased prevalence of scrub typhus has been noted in the asian subcontinents and tsutsugaushi triangle.Scrub thypus is a common infection in sub Himalayan region of India1 and it is known to occur all over India, including Southern India.2 Scrub typhus is a small obligate gram negative, intracellular bacteria, Family rickettsiae, genus orientiae & its Cell wall lacks peptidoglycans and lipopolysaccharides. Primary reserviour, is a chigger/mite, larval stage,trombiculid mite (Leptotrombium daliense and others). Secondary reserviours are mainly rodents & humans. Incubation period is 5-20 days, mean 10-12 days.
Orientia tsutsugamushi is the causative agent & transmitted tohumans through the bite of thrombiculid mites. The mites have a four-stage lifecycle: egg, larva, nymph and adult. It is the accidental disease in humans & chigger (larval) phase is the only stage that is parasitic on animals or humans.3 It divides and breeds within the phagocytes and escape from the cell back into the circulation to continue to proliferate on the endothelium of small blood vessels releasing cytokines which damage endothelial integrity, causing fluid leakage, platelet aggregation, polymorphs and monocyte proliferation, leading to focal occlusive end -angiitis causing microinfarcts.
It is now well established that a majority of sequelae associated with human rickettsioses are the outcome of‘Rickettsial vasculitis’. 4 Especially affects skeletal muscles, skin, lungs, kidneys, brain and cardiac muscles. Cardiovascular system manifestations are mainly due to endothelial cell damage, vasculitis , inflammatory cell infiltration, typhus nodules, new endothelial cell proliferation, thrombosis, ischemia & infarction.4,5 Till now only one case was reported in english literature “acute myocardial infarction following scrub typhus infection”. 6
Severe infections may be complicated by interstitial pneumonia, pulmonary edema, congestive heart failure, circulatory collapse, and a wide array of signs and symptoms of central nervous system dysfunction, including delirium, confusion, and seizures. Death may occur as a result of these complications, usually late in the second week of the illness.
Learning Points
The importance of this case report is too highlight that scrub typhus can cause vasculitis of organ system in the body especially lungs, kidney, brain & cardiac tissue.
References
1. Sharma A, Mahajan S, Gupta ML, Kanga A and Sharma V. Investigation of an Outbreak of Scrub Typhus in the Himalayan Region of India. Jpn J Infect Dis. 2005;58:208 -210
2 . Mathai E, Lloyd G, Cherian E et al. Serological evidence for the continued presence of human rickettsioses in southern India. Annals of Tropical Medicine and Parasitology 2001;95:395 -398.
3 . James MT. Mites and mite -borne disease. In: Harwood RF, ed, Medical Entomology. 6th ed. New York: Macmillan, 1969; 379 -87.
4 . Settle EB, Pinkerton H, Corbett AJ. A pathologic study of tsutsugamushi disease with notes on clinicopathologic correlation. J Lab Clin Med 1945;30:639 -661.
5 . Allen AC, Saitz S. A comparative study of the pathology of scrub typhus( tsutsugamushi disease) and other rickettsial disease. Am J Pathol 1945;21: 6 0 3
6 . Kim DG, Kim JW, Choi YS, Kim SH, Kim SM, Park CG, Seo HS, Oh DJ. Acute myocardial infarction following scrub typhus infection. Int J Cardiol. 2007 Dec 15;123(1):73.