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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 101-103

Scrub Typhus Meningoencephalitis: An Uncommon Cause of Acute Febrile Encephalopathy in the Elderly


1 Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Internal Medicine, Command Hospital (Southern Command), Pune, Maharashtra, India

Date of Submission10-Dec-2020
Date of Acceptance22-Feb-2021
Date of Web Publication21-Jan-2022

Correspondence Address:
Dr. Lt Col Vishal Mangal
Department of Internal Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_187_20

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  Abstract 


Central nervous system infections are an uncommon cause of acute febrile encephalopathy (AFE) in the elderly. Scrub typhus meningoencephalitis is uncommon and often missed in the elderly. A 70-year-old male presented with complaints of intermittent fever, maculopapular rash, and altered sensorium. Physical examination revealed fever, tachycardia, tachypnea, maculopapular rash on the trunk, and all four limbs, and an eschar on the right thigh. Initial laboratory evaluation revealed anemia, thrombocytopenia, and azotemia. The cerebrospinal fluid revealed lymphocytic pleocytosis, elevated proteins with normal glucose, and adenosine deaminase. Weil–Felix test was positive. The diagnosis of scrub typhus meningoencephalitis with acute kidney injury and atypical pneumonia was established. A prompt treatment with injection doxycycline and tablet rifampicin led to an uneventful recovery. We report the first case of scrub typhus meningoencephalitis as the cause of AFE in the elderly. This case highlights the importance of clinical examination in any febrile encephalopathy presenting in endemic areas or travelers returning from such places.

Keywords: Acute febrile encephalopathy, case report, elderly, meningoencephalitis, scrub typhus


How to cite this article:
Kesavan Nair LV, Timmalsugur RK, Mangal V. Scrub Typhus Meningoencephalitis: An Uncommon Cause of Acute Febrile Encephalopathy in the Elderly. J Mar Med Soc 2022;24, Suppl S1:101-3

How to cite this URL:
Kesavan Nair LV, Timmalsugur RK, Mangal V. Scrub Typhus Meningoencephalitis: An Uncommon Cause of Acute Febrile Encephalopathy in the Elderly. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 9];24, Suppl S1:101-3. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/101/336189




  Introduction Top


Scrub typhus is common in India; however, statistics on prevalence, morbidity, and mortality are not available.[1] It is caused by Orientia tsutsugamushi and is characterized by fever, an eschar, lymphadenopathy, and multisystem involvement and usually responds well to doxycycline.[2] In India, the first reported cases were in Himachal Pradesh in 1934.[3] The larval forms of trombiculid mite transmit the disease to humans. The rodents are the natural hosts; however, humans get infected accidentally following the bites of chiggers. The infection spreads through both hematogenous and lymphatic routes. Chills and fever occur by the 3rd–4th day of the bite, and rash and lymphadenopathy appear at the end of the 1st week. The incubation period ranges from 6 to 20 days. Serious complications occur during the 2nd week of illness and comprise pneumonia, hepatitis, acute kidney injury (AKI), acute respiratory distress syndrome, and meningitis.[4] Acute febrile encephalopathy (AFE) is defined as the coexistence of fever and altered mental status in the form of confusion, behavioral changes, disorientation, or other cognitive impairments.[5] The most common cause of AFE in the elderly (age >65 years) is sepsis-associated encephalopathy due to noncentral nervous system (CNS) infections. The most common pathogens associated with CNS infection in AFE in the elderly are Streptococcus pneumoniae, Mycobacterium tuberculosis, Brucella species, herpes virus, Staphylococcus aureus, Pseudomonas species, and Acinetobacter species.[5] Scrub typhus has rarely been reported as a cause of AFE in the elderly. Here, we report such a case of AFE in the elderly who presented early with multisystem involvement and recovered fully with conventional therapy despite being in a high-risk mortality group.


  Case Report Top


A 70-year-old male farmer, with a past medical history of ischemic posterior circulation stroke in 2013 with complete recovery, presented with complaints of intermittent fever with chills and rigors and a maculopapular rash over the trunk of 5-day duration. He also had an altered sensorium of 3-day duration with no headache, vomiting, seizures, or focal neurological deficits. Physical examination revealed fever, tachycardia, disproportionate tachypnea, maculopapular rash on the trunk, and all four limbs, and an eschar on the right thigh [Figure 1]. He did not have evidence of meningism. He had hypoactive delirium and fine bilateral crackles with hypoxemic respiratory failure indicating probable atypical pneumonia. Initial laboratory evaluation revealed anemia, thrombocytopenia, and azotemia [Table 1]. The cerebrospinal fluid (CSF) revealed lymphocytic pleocytosis, elevated proteins with normal glucose, and adenosine deaminase (ADA). He also underwent magnetic resonance imaging of the brain because of AFE [Table 2]. He was evaluated for all the possible tropical infections; however, the Weil–Felix test was positive. He was diagnosed as a case of scrub typhus with meningoencephalitis, AKI, and probable atypical pneumonia and was managed with injection doxycycline intravenous 100 mg twice daily and oral rifampicin 600 mg once a day for 7 days, along with supportive care. The fever and altered sensorium resolved over 2 days, and he was discharged in a stable condition after 10 days.
Figure 1: The red arrow shows the eschar over the medial aspect of the right thigh

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Table 1: Laboratory parameters

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Table 2: Infective workup

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  Discussion Top


The decline in the immune system's capability with age is responsible for the increased susceptibility of aging individuals to infection. Confusion, which is the predominant feature of encephalopathy, is present in up to 50% of elderly hospitalized patients.[6] When confusion is accompanied by fever, the first thing which comes to mind is the possibility of CNS infection; however only 7.4 % of the patients have CNS infection who present with AFE.[7] Scrub typhus meningoencephalitis is an uncommon cause of AFE in the elderly and is very difficult to diagnose because the clinical signs such as fever and neck stiffness have low sensitivity. Our patient presented with fever and altered mental status with the absence of neck rigidity; however, he underwent early diagnostic lumbar puncture because of eschar and high clinical suspicion, which helped in establishing the diagnosis.

“Typhus” is derived from the Greek word “Typos” for “fever with stupor” or smoke and refers to the clouded sensorium of patients of severe rickettsioses. The CNS manifestations are varied and include peripheral neuropathy, Guillain–Barre syndrome, acute transverse myelitis, cerebral microbleeds, infarcts due to secondary CNS vasculitis, meningoencephalitis, and cerebellitis.[8] The clinical manifestations of scrub meningoencephalitis are similar to viral or tubercular meningitis. A period of fever is followed after a variable time with encephalopathy. Neck rigidity is not typical, and eschar, the scrub typhus's pathognomic feature, was infrequently seen in various scrub meningoencephalitis studies.[9] Patients can present as early as 3 days of fever and as late as 2 weeks. There is no sexual preponderance. Our patient was an elderly male farmer who presented with a short duration of fever (5 days) and encephalopathy. He did not have neck stiffness; however, an eschar was present. CSF analysis is always lymphocytic predominant with elevated protein, normal glucose, and ADA levels. CSF polymerase chain reaction is a confirmative test to diagnose scrub meningoencephalitis. However, serum scrub immunoglobulin M ELISA is readily available, and hence, the confirmation of scrub typhus in the setting of clinical features of meningoencephalitis can be done by this method, especially in resource-poor settings.[10] The CSF picture was consistent with the observed analysis in previous studies, and the final diagnosis was made by clinical findings and serology as has been advised in resource constraint settings. The treatment of choice is oral or injectable doxycycline 100 mg twice a day for 1–2 weeks. In a pregnant woman, azithromycin is the drug of choice. In case of inadequate response to doxycycline, chloramphenicol, or rifampicin may be used for treatment. Rifampicin should be used in combination, either with azithromycin or doxycycline, to prevent resistance development. The use of rifampicin in areas with high TB incidence is not routinely recommended.[11] Written informed consent was obtained from the patient to publish the case report.


  Conclusion Top


CNS infection as a cause of AFE in the elderly is uncommon. However, detailed clinical examination can help in establishing the correct diagnosis. Scrub typhus is commonly seen in endemic areas, however, clinicians need to have high index of suspicion, especially in the elderly presenting with AFE.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Viswanathan S, Muthu V, Iqbal N, Remalayam B, George T. Scrub typhus meningitis in South India – A retrospective study. PLoS One 2013;8:e66595.  Back to cited text no. 1
    
2.
Jamil MD, Hussain M, Lyngdoh M, Sharma S, Barman B, Bhattacharya PK. Scrub typhus meningoencephalitis, a diagnostic challenge for clinicians: A hospital based study from North-East India. J Neurosci Rural Pract 2015;6:488-93.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Oaks JS, Ridgway RL, Shirai A, Twartz JC. Scrub typhus. Malaysia: United States Army Medical Research Unit, Institute for Medical Research; 1983. p. 1-107.  Back to cited text no. 3
    
4.
Tsay RW, Chang FY. Acute respiratory distress syndrome in scrub typhus. QJM 2002;95:126-8.  Back to cited text no. 4
    
5.
Emerg Med Int[Internet].2018 Jun 3;3587014 98. Available from: https://doi.org/10.1155/2018/3587014 [Last accessed on 2020 Dec 10].  Back to cited text no. 5
    
6.
Sheybani F, Naderi HR, Sajjadi S. The Optimal Management of Acute Febrile Encephalopathy in the Aged Patient: A Systematic Review. Interdiscip Perspect Infect Dis[Internet]. 2016;5273651. Availab;le from: https://doi.org/10.1155/2016/5273651 [Last accessed on 2020 Dec 10].  Back to cited text no. 6
    
7.
Cagatay AA, Tufan F, Hindilerden F, Aydin S, Elcioglu OC, Karadeniz A, et al. The causes of acute Fever requiring hospitalization in geriatric patients: comparison of infectious and noninfectious etiology. J Aging Res[Internet]. 2010;380892. Available from: https://doi.org/10.4061/2010/380892. [Last accessed on 2020 Dec 10].  Back to cited text no. 7
    
8.
Pai H, Sohn S, Seong Y, Kee S, Chang WH, Choe KW. Central nervous system involvement in patients with scrub typhus. Clin Infect Dis 1997;24:436-40.  Back to cited text no. 8
    
9.
Iqbal N, Mookkappan S, Basheer A. Scrub typhus meningoencephalitis. J Curr Res Sci Med 2015;1:3-5.  Back to cited text no. 9
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10.
Kim DM, Yun NR, Yang TY, Lee JH, Yang JT, Shim SK, et al. Usefulness of nested PCR for the diagnosis of scrub typhus in clinical practice: A prospective study. Am J Trop Med Hyg 2006;75:542-5.  Back to cited text no. 10
    
11.
Varghese GM, Mathew A, Kumar S, Abraham OC, Trowbridge P, Mathai E. Differential diagnosis of scrub typhus meningitis from bacterial meningitis using clinical and laboratory features. Neurol India 2013;61:17-20.  Back to cited text no. 11
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