Clinical profile, complications and outcome of scrub typhus in children: A hospital based observational study in central Nepal
Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. A prospective obs...
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| Published in: | PloS one Vol. 14; no. 8; p. e0220905 |
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| Format: | Journal Article |
| Language: | English |
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13.08.2019
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| ISSN: | 1932-6203, 1932-6203 |
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| Abstract | Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children.
A prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA.
All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%.
Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. |
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| AbstractList | Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children.BACKGROUNDScrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children.A prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA.METHODSA prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA.All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%.RESULTSAll cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%.Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome.CONCLUSIONSScrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. Background Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. Methods A prospective observational study was carried out in children aged 1–16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. Results All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. Conclusions Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. A prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. Background Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. Methods A prospective observational study was carried out in children aged 1–16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. Results All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. Conclusions Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. BackgroundScrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children.MethodsA prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA.ResultsAll cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%.ConclusionsScrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. A prospective observational study was carried out in children aged 1-16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome. |
| Audience | Academic |
| Author | Chaudhary, Nagendra Kurmi, Om P. Shrestha, Sandeep Dhungel, Prativa Regmi, Shanti Shakya, Disuja Neupane, Gagan Pathak, Santosh Dhakal, Prativa |
| AuthorAffiliation | 2 Department of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal 4 Shreegaun Primary Health Care Centre, Dang, Nepal 3 Department of Woman's Health and Development, School of Nursing, Chitwan Medical College, Bharatpur, Nepal 5 Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Canada University of Minnesota, UNITED STATES 1 Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal 6 Division of Respirology, Department of Medicine, McMaster University, Hamilton, Canada |
| AuthorAffiliation_xml | – name: 2 Department of Pediatrics, Universal College of Medical Sciences, Bhairahawa, Nepal – name: 4 Shreegaun Primary Health Care Centre, Dang, Nepal – name: University of Minnesota, UNITED STATES – name: 6 Division of Respirology, Department of Medicine, McMaster University, Hamilton, Canada – name: 5 Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Canada – name: 3 Department of Woman's Health and Development, School of Nursing, Chitwan Medical College, Bharatpur, Nepal – name: 1 Department of Pediatrics, Chitwan Medical College, Bharatpur, Nepal |
| Author_xml | – sequence: 1 givenname: Santosh surname: Pathak fullname: Pathak, Santosh – sequence: 2 givenname: Nagendra orcidid: 0000-0002-3216-8671 surname: Chaudhary fullname: Chaudhary, Nagendra – sequence: 3 givenname: Prativa surname: Dhakal fullname: Dhakal, Prativa – sequence: 4 givenname: Disuja surname: Shakya fullname: Shakya, Disuja – sequence: 5 givenname: Prativa surname: Dhungel fullname: Dhungel, Prativa – sequence: 6 givenname: Gagan orcidid: 0000-0002-8194-7794 surname: Neupane fullname: Neupane, Gagan – sequence: 7 givenname: Sandeep surname: Shrestha fullname: Shrestha, Sandeep – sequence: 8 givenname: Shanti surname: Regmi fullname: Regmi, Shanti – sequence: 9 givenname: Om P. surname: Kurmi fullname: Kurmi, Om P. |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/31408484$$D View this record in MEDLINE/PubMed |
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| ContentType | Journal Article |
| Copyright | COPYRIGHT 2019 Public Library of Science 2019 Pathak et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. 2019 Pathak et al 2019 Pathak et al |
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| DOI | 10.1371/journal.pone.0220905 |
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| References | C Chanta (ref16) 2005; 88 C-S Lee (ref17) 2010; 10 SK Mahajan (ref2) 2008; 75 C-T Huang (ref8) 2009; 40 R Kumar (ref13) 2016; 64 NB Rathi (ref24) 2011; 48 S Sivarajan (ref21) 2016; 5 I El Sayed (ref22) 2018 V Sirisanthana (ref9) 2003; 22 HL Phuong (ref5) 2006; 6 N De Silva (ref12) 2012; 87 N Kumar Bhat (ref7) 2014; 24 S Palanivel (ref11) 2012; 79 M Bal (ref15) 2019; 56 K Kamarasu (ref10) 2007; 126 N Murali (ref18) 2001; 38 HR Somashekar (ref14) 2006; 52 BP Upadhyaya (ref4) 2016; 14 M Vivekanandan (ref20) 2010; 58 R Panpanich (ref23) 2002 M Kumar (ref6) 2012; 5 K Silpapojakul (ref1) 1997; 26 S Pavithran (ref19) 2004; 41 DR Murdoch (ref3) 2004; 70 |
| References_xml | – volume: 56 start-page: 304 issue: 4 year: 2019 ident: ref15 article-title: Profile of Pediatric Scrub Typhus in Odisha, India publication-title: Indian Pediatrics doi: 10.1007/s13312-019-1519-1 – volume: 26 start-page: 794 issue: 6 year: 1997 ident: ref1 article-title: Scrub typhus in the Western Pacific region publication-title: Ann Acad Med Singapore – volume: 52 start-page: 228 issue: 3 year: 2006 ident: ref14 article-title: Magnitude and features of scrub typhus and spotted fever in children in India publication-title: J Trop Pediatr doi: 10.1093/tropej/fmi096 – volume: 75 start-page: 947 issue: 9 year: 2008 ident: ref2 article-title: Pediatric scrub typhus in Indian Himalayas publication-title: Indian J Pediatr doi: 10.1007/s12098-008-0198-z – volume: 6 start-page: 123 issue: 1 year: 2006 ident: ref5 article-title: Dengue as a cause of acute undifferentiated fever in Vietnam publication-title: BMC infectious diseases doi: 10.1186/1471-2334-6-123 – issue: 9 year: 2018 ident: ref22 article-title: Antibiotics for treating scrub typhus publication-title: Cochrane Database of Systematic Reviews doi: 10.1002/14651858.CD002150.pub2 – issue: 3 year: 2002 ident: ref23 article-title: Antibiotics for treating scrub typhus publication-title: Cochrane Database Syst Rev – volume: 87 start-page: 342 issue: 2 year: 2012 ident: ref12 article-title: Scrub Typhus among Pediatric Patients in Dambadeniya:A Base Hospital in Sri Lanka publication-title: Am J Trop Med Hyg doi: 10.4269/ajtmh.2012.12-0170 – volume: 38 start-page: 1393 issue: 12 year: 2001 ident: ref18 article-title: Rickettsial infections in South India—how to spot the spotted fever publication-title: Indian Pediatr – volume: 58 start-page: 24 year: 2010 ident: ref20 article-title: Outbreak of scrub typhus in Pondicherry publication-title: J Assoc Physicians India – volume: 70 start-page: 670 issue: 6 year: 2004 ident: ref3 article-title: The etiology of febrile illness in adults presenting to Patan hospital in Kathmandu, Nepal publication-title: Am J Trop Med Hyg doi: 10.4269/ajtmh.2004.70.670 – volume: 64 start-page: 30 issue: 12 year: 2016 ident: ref13 article-title: Clinical Profile and Complications of Scrub Typhus: Hospital-Based Study in Sub-Himalayan Region publication-title: J Assoc Physicians India – volume: 5 start-page: 82 issue: 1 year: 2012 ident: ref6 article-title: Scrub typhus in children at a tertiary hospital in southern India: clinical profile and complications publication-title: J Infect Public Health doi: 10.1016/j.jiph.2011.11.001 – volume: 22 start-page: 341 issue: 4 year: 2003 ident: ref9 article-title: Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children publication-title: Pediatr Infect Dis J doi: 10.1097/01.inf.0000059400.23448.57 – volume: 126 start-page: 128 issue: 2 year: 2007 ident: ref10 article-title: Serological evidence for wide distribution of spotted fevers & typhus fever in Tamil Nadu publication-title: Indian J Med Res – volume: 24 start-page: 387 issue: 4 year: 2014 ident: ref7 article-title: Scrub typhus in children at a tertiary hospital in north India: clinical profile and complications publication-title: Iran J Pediatr – volume: 79 start-page: 1459 issue: 11 year: 2012 ident: ref11 article-title: Clinical profile of scrub typhus in children publication-title: Indian J Pediatr doi: 10.1007/s12098-012-0721-0 – volume: 5 start-page: 91 year: 2016 ident: ref21 article-title: Clinical and paraclinical profile, and predictors of outcome in 90 cases of scrub typhus, Meghalaya, India publication-title: Infect Dis Povert doi: 10.1186/s40249-016-0186-x – volume: 10 start-page: 216 year: 2010 ident: ref17 article-title: Clinical significance of hypoalbuminemia in outcome of patients with scrub typhus publication-title: BMC Infect Dis doi: 10.1186/1471-2334-10-216 – volume: 14 start-page: 122 issue: 33 year: 2016 ident: ref4 article-title: Scrub Typhus: An Emerging Neglected Tropical Disease in Nepal publication-title: J Nepal Health Res Counc – volume: 41 start-page: 1254 issue: 12 year: 2004 ident: ref19 article-title: Scrub typhus publication-title: Indian Pediatr – volume: 48 start-page: 867 issue: 11 year: 2011 ident: ref24 article-title: Rickettsial diseases in central India: proposed clinical scoring system for early detection of spotted fever publication-title: Indian Pediatr doi: 10.1007/s13312-011-0141-7 – volume: 88 start-page: 1867 issue: 12 year: 2005 ident: ref16 article-title: Clinical study of 20 children with scrub typhus at Chiang Rai Regional Hospital publication-title: J Med Assoc Thail Chotmaihet Thangphaet – volume: 40 start-page: 789 issue: 4 year: 2009 ident: ref8 article-title: Scrub typhus in children in a teaching hospital in eastern Taiwan, 2000–2005 publication-title: Southeast Asian J Trop Med Public Health |
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