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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 223-225

Scrub and spleen: Scrub typhus with a splenic infarct


Department of Medicine, Kasturba Medical College, Manipal, Karnataka, India

Date of Submission04-May-2020
Date of Decision19-Jun-2020
Date of Acceptance26-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Dr. Sudha Vidyasagar
Department of Medicine, Kasturba Medical College, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJMS.INJMS_36_20

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  Abstract 


Scrub typhus is a mite-borne infection endemic in India. Among the spectrum of complications associated with this tropical illness are manifestations such as encephalitis, acute respiratory distress syndrome, myocarditis, hepatomegaly, splenomegaly, and pancreatitis. Although splenomegaly is a known association among the gastrointestinal complications, splenic infarcts are sparsely reported in the literature. This case is about a woman with scrub typhus who presented with unexplained pain abdomen which was diagnosed as a splenic infarct.

Keywords: Rickettsial infections, scrub typhus, splenic infarct


How to cite this article:
Sukumar CA, Poduval AR, Bhat N, Vidyasagar S. Scrub and spleen: Scrub typhus with a splenic infarct. Indian J Med Spec 2020;11:223-5

How to cite this URL:
Sukumar CA, Poduval AR, Bhat N, Vidyasagar S. Scrub and spleen: Scrub typhus with a splenic infarct. Indian J Med Spec [serial online] 2020 [cited 2021 Mar 4];11:223-5. Available from: http://www.ijms.in/text.asp?2020/11/4/223/295488




  Introduction Top


Scrub typhus is a rickettsial infection caused by Gram-negative Orientia tsutsugamushi. It is transmitted by the bite of the trombiculid mite (chigger). Scrub typhus is widely prevalent in the Indian subcontinent and accounts for 30%–40% hospitalizations for undifferentiated fever.[1] Complications associated with scrub typhus include acute respiratory distress syndrome, interstitial pneumonia, acute renal failure, meningoencephalitis, gastrointestinal bleeding, and multiple organ failure.[2]

Intra-abdominal organ involvement is also common, especially of the liver, gallbladder, kidneys, and pancreas.[3] However, splenic involvement is rare, and there are only a few such documented cases. We report a case of proven scrub typhus infection manifesting with a splenic infarct in a tertiary care hospital in South India.


  Case Report Top


A 40-year-old woman from a small district of South India presented at the emergency department with complaints of high-grade fever with chills and rigors for the past 15 days. She had a sharp, constant pain over her left upper abdomen. Her vitals were stable, with a temperature of 102.4°F. Gross pallor was present with multiple discrete inguinal lymphadenopathy. No eschar was present. Mild tenderness was present over her left hypochondrium, with a palpable spleen measuring 6 cm. A palpable liver was also present extending 3 cm below the right costal margin. Laboratory investigations are shown in [Table 1].
Table 1: Summary of the laboratory investigations

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Ultrasound of abdomen showed an enlarged spleen with a few wedge-shaped hypoechoic areas in the parenchyma. This was suggestive of a splenic infarct. Computed tomography (CT) imaging of the abdomen [Figure 1] and [Figure 2] revealed an enlarged spleen measuring 16.5 cm × 7.3 cm, with multiple wedge-shaped areas of nonenhancement in the splenic parenchyma suggestive of a splenic infarct. The patient was started on a course of oral doxycycline 100 mg bd for 1 week. Iron supplementation was also given for iron-deficiency anemia. The patient symptomatically improved and was discharged on completion of her antibiotic course.
Figure 1: Computed tomography imaging(axial section) showing the splenic infarct. Arrow indicating splenic infarct

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Figure 2: Computed tomography imaging (coronal section)showing the splenic infarct. Arrow indicating splenic infarct

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  Discussion Top


Scrub typhus is geographically distributed across tropical and subtropical countries. It is endemic in India, Pakistan, China, Bangladesh, Indonesia, Vietnam, and Japan.[4] The estimated annual incidence of scrub typhus in India was found to be 0.8/1000 people, according to a large retrospective cohort study in India. This rickettsial disease can progress into life-threatening complications and death in 6%–10% untreated cases.[5] However, the treatment on timely diagnosis comprises a course of inexpensive and effective antibiotics such as doxycycline or azithromycin.[6]

Scrub typhus can progress into a spectrum of complications ranging from acute respiratory distress syndrome, meningoencephalitis, myocarditis, shock, and renal failure.[6] Pulmonary involvement is the most common complication of scrub typhus and presents as interstitial pneumonia. Cardiac complications such as myocarditis and central nervous system involvement in the form of meningoencephalitis also occur frequently.[2]

Abdominal complications in scrub typhus include abdominal pain, loose stools, pancreatitis, gastrointestinal bleeding, hepatomegaly, and splenomegaly.[6] The underlying pathophysiology implicated is the disseminated or focal gastrointestinal vasculitis. There is an invasion of the endothelial cells by the phagocytes which occurs as an immune response of the body to the rickettsial antigen.[7],[8]

Splenic infarction is caused by compromise of the splenic vascular supply in hematological diseases, embolic disorders, trauma, and infections. The pathophysiology in various tropical illnesses causing splenic infarction varies. However, in splenic infarcts secondary to scrub typhus, vasculitis has been implicated as the underlying cause.[8] The treatment includes a course of doxycycline or azithromycin. This also relieves symptoms of abdominal pain that occur secondary to splenic infarcts. Although splenomegaly is seen in up to 8% of cases of scrub typhus, splenic infarct is rare.[9]

There are few such reported cases found in the literature. Two cases of scrub typhus with splenic infarcts were first reported in 2004 from Korea.[9] This was followed by another case report from Korea in 2015 by Durey et al.[10] There was a case reported from Vellore, South India, in 2014 by Raj et al.[8] Another more recent case report from North India also reported a young male with fever and pain abdomen. Splenic infarct was confirmed on CT abdomen, and he was finally confirmed to be scrub typhus positive after all other etiologies were ruled out.[11] All previously reported cases of splenic infarct presented in a similar fashion of fever with left hypochondrium pain and splenomegaly. In another case report by Hwang and Lee, a middle-aged woman with fever and eschar was admitted. However, she did not present with pain abdomen. A CT abdomen done in view of abnormal liver function tests showed a wedge-shaped splenic infarct.[12] All cases were treated with doxycycline antibiotics and improved clinically and radiologically. Although our case did not present with thrombocytopenia or eschar, she had left upper quadrant pain and tenderness. The splenic infarct was delineated on ultrasound abdomen and confirmed on CT findings. She improved with doxycycline treatment. The follow-up CT scan was not done, and the patient was requested to repeat ultrasound in 2 weeks on follow-up. The follow-up ultrasound scan done 2 weeks later showed a decrease in the size of the infarcts, and she was asymptomatic.


  Conclusion Top


Among the complications of scrub typhus, splenic infarct is a rare cause of unexplained pain abdomen. This case highlights the infrequent but underdiagnosed association of scrub typhus with splenic infarcts. Therefore, acute-onset pain abdomen should be evaluated with an ultrasound or CT abdomen to aid in the detection of splenic infarcts in scrub typhus.

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Devamani CS, Prakash JA, Alexander N, Suzuki M, Schmidt WP. Hospitalisations and outpatient visits for undifferentiated fever attributable to scrub typhus in rural South India: Retrospective cohort and nested case-control study. PLoS Negl Trop Dis 2019;13:e0007160.  Back to cited text no. 1
    
2.
Tsay RW, Chang FY. Serious complications in scrub typhus. J Microbiol Immunol Infect 1998;31:240-4.  Back to cited text no. 2
    
3.
Kim SJ, Chung IK, Chung IS, Song DH, Park SH, Kim HS, et al. The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus. Endoscopy 2000;32:950-5.  Back to cited text no. 3
    
4.
Kelly DJ, Fuerst PA, Ching WM, Richards AL. Scrub typhus: The geographic distribution of phenotypic and genotypic variants of Orientia tsutsugamushi. Clin Infect Dis 2009;48 Suppl 3:S203-30.  Back to cited text no. 4
    
5.
Taylor AJ, Paris DH, Newton PN. A systematic review of mortality from untreated scrub typhus (Orientia tsutsugamushi). PLoS Negl Trop Dis 2015;9:e0003971.  Back to cited text no. 5
    
6.
Chrispal A, Boorugu H, Gopinath KG, Prakash JA, Chandy S, Abraham OC, et al. Scrub typhus: An unrecognized threat in South India-Clinical profile and predictors of mortality. Trop Doct 2010;40:129-33.  Back to cited text no. 6
    
7.
Varghese GM, Trowbridge P, Janardhanan J, Thomas K, Peter JV, Mathews P, et al. Clinical profile and improving mortality trend of scrub typhus in South India. Int J Infect Dis 2014;23:39-43.  Back to cited text no. 7
    
8.
Raj SS, Krishnamoorthy A, Jagannati M, Abhilash KP. Splenic infarct due to scrub typhus. J Glob Infect Dis 2014;6:86-8.  Back to cited text no. 8
    
9.
Jung JO, Jeon G, Lee SS, Chung DR. Two cases of tsutsugamushi disease complicated with splenic infarction. Korean J Med 2004;67:S932-6.  Back to cited text no. 9
    
10.
Durey A, Kwon HY, Park YK, Baek J, Han SB, Kang JS, et al. A case of scrub typhus complicated with a splenic infarction. Infect Chemother 2018;50:55-8.  Back to cited text no. 10
    
11.
Goyal MK, Porwal YC, Gogna A, Gulati S. Splenic infarct with scrub typhus: a rare presentation. Trop Doct 2020;50:234-6.  Back to cited text no. 11
    
12.
Hwang JH, Lee CS. Incidentally discovered splenic infarction associated with scrub typhus. Am J Trop Med Hyg 2015;93:435.  Back to cited text no. 12
    


    Figures

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    Tables

  [Table 1]



 

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