A case of scrub typhus without eschar located in a rare location

doi:10.3969/j.issn.1004-583X.2024.03.009

Abstract

Abstract:

Objective This case report aims to present a unique instance of atypical rash resulting from Orientia tsutsugamushi (Ot) infection. The primary objective is to augment the comprehension of the pathogenic microorganism and associated diseases among clinical practitioners, thus offering valuable insights for clinical diagnosis and treatment approaches. Methods A retrospective analysis was performed on a scrub typhus (ST) case admitted to First Hospital of Shanxi Medical University in June 2023, supplemented by a comprehensive review of pertinent literature. Results The patient, a 77-year-old male, presented with a persistent rash on the left forearm lasting one week, concomitant with a four-day febrile episode. Due to the initial diagnosis of soft tissue infection, the patient underwent empirical anti-infection therapy involving intravenous administration of ceftriaxone sodium and cefoperazone sodium sulbactam sodium. Despite treatment, the patient's fever persisted, and the rash failed to ameliorate. Notably, pathogen metagenomic next-generation sequencing (mNGS) testing confirmed Ot positivity. Subsequent management entailed oral administration of doxycycline hydrochloride enteric-coated capsules, resulting in prompt normalization of body temperature in five hours. Substantial clinical improvement was observed after three days, facilitating the patient's discharge. A follow-up examination one month post-discharge revealed an absence of complications. Conclusion Cases of ST are relatively infrequent, characterized by a spectrum of intricate and diverse clinical manifestations, particularly challenging in patients lacking typical rash presentations, thereby complicating diagnostic endeavors. While the overall mortality rate associated with ST is relatively low, delayed diagnosis and inadequate provision of targeted therapies may precipitate severe complications, potentially jeopardizing patient outcomes. Consequently, clinicians are urged to fortify their comprehension of the pathogenic microorganism and its infectious sequelae, emphasizing early detection and proactive intervention to avert grave complications.

Key words: scrub typhus, infection, metagenomic next-generation sequencing, case report

CLC Number:

R513.2

Feng Yu, Lang Xiaoqing, Wang Gang, Guo Shuping. A case of scrub typhus without eschar located in a rare location[J]. Clinical Focus, 2024, 39(3): 249-252.

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URL: https://huicui.hebmu.edu.cn/EN/10.3969/j.issn.1004-583X.2024.03.009

https://huicui.hebmu.edu.cn/EN/Y2024/V39/I3/249

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References 26

[1]	Yue Y, Ren D, Liu X, et al. Spatio-temporal patterns of scrub typhus in mainland China, 2006-2017[J]. PLoS Negl Trop Dis, 2019, 13(12):e0007916.
[2]	Musa TH, Ahmad T, Wana MN, et al. The epidemiology, diagnosis and management of scrub typhus disease in China[J]. Hum Vaccin Immunother, 2021, 17(10):3795-3805.
[3]	Itoh K, Kabata D, Shigemi H, et al. Evaluation of tetracycline and fluoroquinolone therapy against Japanese spotted fever: Analysis based on individual data from case reports and case series[J]. Int J Antimicrob Agents, 2023, 62(2):106895.
[4]	Weitzel T, Martínez-Valdebenito C, Acosta-Jamett G, et al. Notes from the field: Scrub typhus outbreak-Los Lagos Region, Chile, January-February 2023[J]. MMWR Morb Mortal Wkly Rep, 2023, 72(27):753-754.
[5]	Huang X, Xie B, Long J, et al. Prediction of risk factors for scrub typhus from 2006 to 2019 based on random forest model in Guangzhou, China[J]. Trop Med Int Health, 2023, 28(7):551-561.
[6]	Singh H, Selvam S, Suri V, et al. Multiple eschars in scrub typhus[J]. Am J Trop Med Hyg, 2023, 109(3):499-500.
[7]	Chung MH, Lee JS, Im JH. Antibiotic combination therapy for severe scrub typhus: Is it necessary[J]Infect Chemother, 2023, 55(2):179-184.
[8]	Singh J, Dinkar A, Kumar N, et al. Digital gangrene associated with scrub typhus: A case series[J]. Am J Trop Med Hyg, 2024, 110(3):497-500.
[9]	Lu M, Zhou D, Xie S, et al. Genetic recombination of Orientia tsutsugamushi strains from scrub typhus patients in Guangxi, Southwest China, and the analysis of clinical features[J]. Microbes Infect, 2023, 25(5):105098.
[10]	Nallan K, Rajan G, Sivathanu L, et al. Molecular detection of multiple genotypes of Orientia tsutsugamushi causing scrub typhus in febrile patients from theni district, South India[J]. Trop Med Infect Dis, 2023, 8(3):174.
[11]	Xu G, Walker DH, Jupiter D, et al. A review of the global epidemiology of scrub typhus[J]. PLoS Negl Trop Dis, 2017, 11(11):e0006062.
[12]	Alam AM, Gillespie CS, Goodall J, et al. Neurological manifestations of scrub typhus infection: A systematic review and meta-analysis of clinical features and case fatality[J]. PLoS Negl Trop Dis, 2022, 16(11):e0010952.
[13]	Raghunathan V, Dhaliwal M, Singhi P, et al. Scrub typhus associated with Guillain-Barré syndrome (GBS)[J]. Indian J Pediatr, 2022, 89(11):1129-1130.
[14]	Zaman K. Scrub typhus, a salient threat: Needs attention[J]. PLoS Negl Trop Dis, 2023, 17(6):e0011427.
[15]	Trent B, Fisher J, Soong L. Scrub typhus pathogenesis: Innate immune response and lung injury during orientia tsutsugamushi infection[J]. Front Microbiol, 2019, 10:2065.
[16]	Kim J, Seok H, Jeon JH, et al. Association of scrub typhus with incidence of dementia: A nationwide population-based cohort study in Korea[J]. BMC Infect Dis, 2023, 23(1):127. doi: 10.1186/s12879-023-08107-0 pmid: 36859244
[17]	Liang Y, Aditi, Onyoni F, et al. Brain transcriptomics reveal the activation of neuroinflammation pathways during acute Orientia tsutsugamushi infection in mice[J]. Front Immunol, 2023, 14:1194881.
[18]	Trent B, Liang Y, Xing Y, et al. Polarized lung inflammation and Tie2/angiopoietin-mediated endothelial dysfunction during severe Orientia tsutsugamushi infection[J]. PLoS Negl Trop Dis, 2020, 14(3):e0007675.
[19]	Evans SM, Rodino KG, Adcox HE, et al. Orientia tsutsugamushi uses two Ank effectors to modulate NF-κB p65 nuclear transport and inhibit NF-κB transcriptional activation[J]. PLoS Pathog, 2018, 14(5):e1007023.
[20]	Gonzales C, Liang Y, Fisher J, et al. Alterations in germinal center formation and B cell activation during severe Orientia tsutsugamushi infection in mice[J]. PLoS Negl Trop Dis, 2023, 17(5):e0011090.
[21]	姜天俊, 江佳富, 齐文杰. 恙虫病临床诊疗专家共识[J]. 中国人兽共患病学报, 2024, 40(1):1-6.
[22]	PLOS Neglected Tropical Diseases Editors. Expression of concern: Use of eschar swabbing for the molecular diagnosis and genotyping of Orientia tsutsugamushi causing scrub typhus in Quang Nam province, Vietnam[J]. PLoS Negl Trop Dis, 2022, 16(12):e0010975.
[23]	Sharda SC, Bisht K, Sharma V, et al. Direct diagnosis of scrub typhus by full-length 16S ribosomal RNA gene analysis using Oxford Nanopore sequencing[J]. Int J Infect Dis, 2022, 125:132-134. doi: 10.1016/j.ijid.2022.10.040 pmid: 36332903
[24]	Sun CB, Ma Z, Liu Z. Case report: Optic neuritis as the initial presentation of Orientia tsutsugamushi infection detected by metagenomic next-generation sequencing[J]. Front Immunol, 2023, 14:1129246.
[25]	Guan XG, Zhou SX, Zhang AR, et al. Clinical outcomes of doxycycline, azithromycin and chloramphenicol for the treatment of patients with severe scrub typhus[J]. Int J Antimicrob Agents, 2022, 60(4):106647.
[26]	Varghese GM, Dayanand D, Gunasekaran K, et al. Intravenous doxycycline, azithromycin, or both for severe scrub typhus[J]. N Engl J Med, 2023, 388(9):792-803.