Acute Parkinsonism and Cerebral Salt-wasting-related Hyponatremia in Scrub Typhus

Scrub typhus is a multisystem disease, and the respiratory system is commonly involved. Scrub typhus-related parkinsonism has been reported in three patients previously, and none of them underwent a lumbar puncture. Cerebral salt wasting is generally observed in vascular emergencies of the brain. We report a patient with acute parkinsonism and cerebral salt wasting syndrome, a combination of which has not been previously reported in scrub typhus. A 50-year-old farmer presented with an acute febrile illness of two weeks' duration and a one-day history of parkinsonism symptoms. His workup revealed hypoosmolar hyponatremia, increased urinary sodium excretion, hepatorenal and hematological dysfunction, and normal findings on cerebrospinal fluid examination. Clinical and biochemical improvement was noticed with the institution of doxycycline. Empirical doxycycline may be needed in patients with acute parkinsonism following an acute febrile illness in areas endemic for scrub typhus. Better biochemical facilities in resource-poor tropical countries would help in evaluating the etiology of hyponatremia due to infectious causes.