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Case Presentation 3
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CASE PRESENTATION
Gopika JagotaMBBS 2011
A 48 year male, lab assistant by profession presented to the casualty of PGIMS, Rohtak with following complaints:
Fever × 10 daysDifficulty in breathing × 3 days
HISTORY OF PRESENT ILLNESS• FEVERHigh grade fever since 10 days, acute in onset a/w rigors and chills; no diurnal variation.Relieved by medication with no aggravating factor.
No h/o cough/epectoration, burning micturition, sore throat, cold, abdominal complaints and altered sensorium.
• SHORTNESS OF BREATH There is history of shortness of breath since 3 days which is gradually increasing. Now present even at rest(MRC grade 4)
Past history, personal history, family history: Not significant
PHYSICAL EXAMINATION• GPE: General appearance- Patient was febrile. He was calm,
conscious, well oriented to time, place and person.
• Pallor⁻,Icterus⁺,Clubbing⁻,Cyanosis⁻, Pedal edema⁻, LAP⁻,JVP⁻
• B.P-116/80 mmHg, Pulse Rate- 78/min
• Resp. system:Patient tachypneic: 24/min. Bilateral basal crepts were present. Po₂: 74.6 mmHg
• No rash was seen. • Other systemic examinations were within normal range
An eschar is seen on left backside of abdomen. It has a black central lesion with erythematous boundaries.
Bilateral lung consolidation and pleural effusion
ECG NORMAL
WORKING DIAGNOSIS
DIFFERENTIALS POSITIVE FINDINGSRickettsial infection Fever with eschar c/o ALI and jaundice
Hepatorenal dysfunction
Dengue Fever with decreased platelet countMalaria Fever associated with rigors and chillsLeptospiral infection Biphasic illness with hepatorenal involvement
Hepatitis Fever with hepatic involvement
Sepsis with MODS Fever with hepatorenal involvement and ALI
LAB INVESTIGATIONS
Hb 12.2 g/dl
TLC 5800/cmm
Platelets 1.31 lac/cmm
SGOT 94mg/dl
SGPT 127mg/dl
S. bilirubin 2.3mg/dl(C=0.5mg/dl;UC=1.8mg/dl)
S. lactate Normal(15mg/dl)
Blood urea 108mg/dlUSG Mild bilateral
pleural effusionHBs Ag NegativeDengue serology Negative
Malaria card Ag Negative
Leptospira serology Negative
Rickettsial serology Positive for scrub typhus
MANAGEMENT• A: Airways- The airways were patent
• B: Breathing- Patient was tachypneic; so was kept on ventilatory support.
• C: Circulation was normal. Hydration was done with i.v fluids.
• D: Drugs- Doxycycline,100mg/day BD; Piperacillin, and Azithromycin (till cause had not been established)
With definitive diagnosis of scrub typhus all other antibiotics were stopped and Doxycycline continued for 15 days.
DEFINITIVE DIAGNOSIS
SCRUB TYPHUS• Clinical findings: Fever with eschar with complication of
acute lung injury and jaundice. Hepatorenal dysfunction.
• Response to Doxycycline is seen
• Serology: Significant titres of >4 were found in serology for Orientia tsutsugamushi; causative organism of Scrub Typhus.
DISCUSSION
• Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi via bite of larval stage of chigger. I.P.: 6-10 days.• Clinical features: Fever, generalized or regional LAP,
maculopapular rash, severe headache or myalgia• A painless papule is seen on the bite site which later ulcerates
and forms a black eschar in a variable population (50%)• Complications: Jaundice, meningoencephalitis, myocarditis,
ARDS, renal failure.
Chigger
DISCUSSIONSTAGES CLINICAL
MANIFETATIONLAB DIAGNOSIS
STAGE 1
• Local infection• Bacteremia
• Bite is seen• Fever, high grade
Cultural sensitivity(c/s) of specimen from• Scrapings from bite• Blood
STAGE 2 (Immune response)
Fever subsides Serology +/-c/s
STAGE 3(a. Recovery) Fever subsides Serology positiveSTAGE 3(b. Bacteremia)
• High grade fever
• Vasculitis
• c/s for fastidious organism
• Vasculitic lesion- Biopsy is taken- c/s
STAGE 4 (convalescense)
- Serology positive
CONCLUSION
• Rickettsiosis is not uncommon• Should always be kept as a differential for
“undifferentiated fever”• Eschar= pathognomic• Early initiation of Antibiotics= affects mortality• Antibiotics= empirical• Later on the basis of reports- Descalation
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