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Tsutsugamushi Disease (Scrub Typhus) Meningoencephalitis in North Eastern India: A Prospective Study
S R Sharma1, H Masaraf1, K G Lynrah1
1Department of Neurology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India.
Background:
Scrub typhus is rampant in northern, eastern, and southern India. Central nervous system involvement in the form of meningitis or meningoencephalitis is common in scrub typhus. As specific laboratory methods remain inadequate or inaccessible in developing countries, prompt diagnosis is often difficult.
Aim:
The aim of this study was to characterize neurological complications in scrub typhus from northeastern region of India.
Subjects And Methods:
We did a prospective study of scrub meningoencephalitis at North Eastern Indira Gandhi Regional Institute of Medical Sciences among patients admitted to hospital between October 2009 and November 2011. The diagnosis was made based on the clinical pictures, presence of an eschar, and a positive Weil-Felix test (WFT) with a titer of >1:160 and if required a positive scrub IgM enzyme-linked immunosorbent assay. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits, and magnetic resonance imaging (MRI) brain performed if needed.
Results:
Twenty-three patients of scrub typhus meningitis that were serologically confirmed were included in the study. There were 13 males and 10 females. Fever ≥1 week was the most common manifestation (39.1%). Interestingly, none had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 17 cells/μL, 90%, 86 mg/dL, 0.6605 and 3.6 U/mL, respectively. All patients were treated with doxycycline. There was no mortality in our study.
Conclusions:
Absence of Eschar does not rule out scrub typhus. Clinical features and CSF findings can mimic tuberculous meningitis so misdiagnosis may lead to unwarranted prolonged empirical antituberculous therapy in cases of lymphocytic meningoencephalitis. Delay in treatment can be potentially fatal. WFT still serves as a useful and affordable diagnostic tool for this disease in resource-poor countries.
Insights
Scrub typhus can cause meningitis even without an eschar, and diagnosis can be challenging in resource-poor areas. Early treatment with doxycycline is crucial to prevent fatal outcomes.
Area of Science:
- Infectious Diseases
- Neurology
- Medical Microbiology
Background:
- Scrub typhus is prevalent in India, frequently causing central nervous system complications like meningitis and meningoencephalitis.
- Accurate laboratory diagnostics for scrub typhus are often limited in developing countries, hindering timely diagnosis.
- Neurological involvement in scrub typhus presents diagnostic challenges due to its varied clinical manifestations.
Purpose of the Study:
- To characterize the neurological complications of scrub typhus in the northeastern region of India.
- To identify key clinical and cerebrospinal fluid (CSF) findings in scrub typhus meningoencephalitis.
- To evaluate diagnostic methods for scrub typhus in a resource-limited setting.
Main Methods:
- A prospective study of scrub meningoencephalitis patients was conducted between October 2009 and November 2011.
- Diagnosis was based on clinical presentation, eschar presence (though noted as absent in this series), Weil-Felix test (WFT) titers >1:160, and scrub IgM ELISA.
- Lumbar puncture and MRI brain were performed for patients with specific neurological symptoms.
Main Results:
- Twenty-three serologically confirmed scrub typhus meningitis cases were analyzed; 13 males and 10 females.
- Fever lasting over a week was the most common symptom (39.1%); notably, no patients had an eschar.
- Cerebrospinal fluid analysis revealed a median cell count of 17 cells/μL, 90% lymphocytes, and protein levels of 86 mg/dL. All patients responded to doxycycline treatment, with no mortality.
Conclusions:
- The absence of an eschar does not exclude scrub typhus diagnosis.
- Clinical and CSF findings in scrub typhus lymphocytic meningoencephalitis can mimic tuberculous meningitis, risking misdiagnosis and delayed treatment.
- The Weil-Felix test remains a valuable and affordable diagnostic tool for scrub typhus in resource-limited settings, emphasizing the need for prompt treatment.
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