Scrub Typhus Involving Central Nervous System, India, 2004–2006 | CDC EID

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Volume 16, Number 10–October 2010
Letter
Scrub Typhus Involving Central Nervous System, India, 2004–2006

Sanjay K. Mahajan Comments to Author, Jean-Marc Rolain, Anil Kanga, and Didier Raoult
Author affiliations: Indira Gandhi Medical College, Shimla, India (S.K. Mahajan, A. Kanga); and Université de la Méditerranée, Marseille, France (J.-M. Rolain, D. Raoult)

Suggested citation for this article

To the Editor: Scrub typhus, caused by Orientia tsutsugamushi, is one of the most common infectious diseases of rural southern Asia, southeastern Asia, and the western Pacific. The disease is transmitted to humans by the bite of larvae of trombiculid mites harboring the pathogen. The disease often appears as a nonspecific febrile illness. The clinical picture of scrub typhus is typically associated with fever, rash, myalgia, and diffuse lymphadenopathy (1). Immunofluorescence assay (IFA) is the test of choice for serodiagnosis of rickettsial diseases (2). Scrub typhus has been reported from northern, eastern, and southern India, and its presence has been documented in at least 11 Indian states (3–7).

Our study’s goal was to retrospectively analyze data of patients with scrub typhus involving the central nervous system. Scrub typhus was suspected on the basis of clinical signs such as febrile illness or fever with rash or eschar. The fever workup profile (Widal agglutination test, peripheral smear, blood, and urine culture) was noncontributory. Blood samples were obtained after patients gave informed consent. All patients with clinically suspected scrub typhus received antirickettsial drugs (doxycycline and/or azithromycin) empirically. IFA and PCR of blood samples were performed to confirm scrub typhus following standard protocol (3). DNA was extracted from the blood sample (buffy coat) by using QIAamp DNA Mini Kit (QIAGEN GmbH, Hilden, Germany) according to the manufacturer’s instructions. A standard PCR specific for the 56-kDa protein with forward and reverse primers (OtsuF: 5¢-AATTGCTAGTGCAATGTCTG-3¢ and OtsuR: 5¢-GGCATTATAGTAGGCTGAG-3¢) was performed (3). PCR products were purified by using the QIAquick PCR Purification Kit (QIAGEN) according to the manufacturer’s instructions. Sequencing reactions were done by using a DNA sequencing kit, dRhodamine Terminator Cycle Sequencing Ready Reaction Mix (Applied Biosystems, Foster City, CA, USA). Sequencing was performed on an ABI PRISM 310 DNA Sequencer (Applied Biosystems). The obtained sequences were identified by comparison with sequences available in GenBank by using the BLAST software (http://blast.ncbi.nlm.nih.gov) (3).

During 2004–2006, scrub typhus was confirmed in 27 patients; 4 had features of central nervous system involvement. All 4 had fever with altered sensorium and meningeal signs; 2 had seizures. No neurologic focal deficit was noted, but all showed cerebrospinal fluid abnormalities. One patient had an eschar, but none had a rash. Serum of 2 patients was subjected to IFA; both samples showed high titers (Table), and PCR for blood was positive for O. tsutsugamushi for all patients. Serum was not subjected to examination for leptospirosis. Patients were treated mainly on the basis of clinical grounds because results of serology were not available immediately. Some clinical features of scrub typhus and leptospirosis are similar, and dual infections have been reported (8); therefore, antimicrobial drugs active against both leptospirosis and scrub typhus were included in treatment regimens. One patient received doxycycline and azithromycin, and the remaining 3 received ceftriaxone in addition to doxycycline. Two patients improved, 1 died, and 1 left hospital against medical advice. The clinical and laboratory details, treatments, and outcomes of all patients are given in the Table.

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Scrub Typhus Involving Central Nervous System, India, 2004–2006 | CDC EID

Suggested Citation for this Article

Mahajan SK, Rolain J-M, Kanga A, Raoult D. Scrub typhus involving central nervous system, India, 2004–2006 [letter]. Emerg Infect Dis [serial on the Internet]. 2010 Oct [date cited].
http://www.cdc.gov/EID/content/16/10/1641.htm

DOI: 10.3201/eid1610.100456