Pediatric Scrub Typhus Clinical Presentation

  • Author: David J Cennimo, MD, FACP, FAAP, AAHIVS; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 30, 2012
 

History

Patients with scrub typhus may present early or later in the course of their disease. In the United Sates, a history of travel to the endemic area must be sought, specifically probing for exposures in rural areas and contact with vegetation or the ground.[1, 4, 10]

The inoculation through the bite of the chigger is often painless and unnoticed. The incubation period lasts 6-20 days (average 10 d). A small painless papule initially appears at the site of infection and enlarges gradually. An area of central necrosis develops and is followed by eschar formation. The eschar (if present) is well developed at the initiation of the fevers, which may drive the patient to seek medical attention.[1, 2, 9, 24, 25]

Next

Physical

  • Approximately 50% of patients with primary infection and 30% of patients with recurrent infection develop an eschar at the inoculation site. Given the appropriate history, the eschar is often pathognomonic but may be missed by inexperienced observers. In prospective studies, trained investigators were able to locate an eschar on 68-87% of patients.[6, 24] In adults, the eschar is often truncal, whereas children may have lesions in the perineum.[26] Multiple eschars may be present.[2] The eschar may also abrade leaving an ulcer reminiscent of primary syphilis.
  • Patients experience abrupt onset of high fever (104-105°F), headache, malaise, and myalgia approximately 10 days after infection. At that time, the eschar (if present) is well formed. Fever is the most commonly reported complaint, occurring more than 98% of the time.[1, 9] Tender regional or generalized lymphadenopathy may provide a clue to diagnosis and is reported in 40-97% of cases. Less frequently, ocular pain, wet cough, malaise, and injected conjunctiva are present.[2, 6, 24, 9, 27]
  • Toward the end of the first week, approximately 35% (reported ranges 15-93%) of patients develop a centrifugal macular rash on the trunk. The rash may progress to become papular.[2, 9, 25] It may be transient and easily missed.[1]
  • Some patients may have CNS involvement with tremors, nervousness, slurred speech, nuchal rigidity, or deafness during the second week of the disease. However, results from the cerebrospinal fluid (CSF) examination are either normal or indicate a low number of monocytes. Severe CNS involvement such as seizure or coma are rare. If acute hearing loss is present (reported in as many as one third of patients in some reports), it strongly points toward scrub typhus.[1, 4]
  • Some evidence of pulmonary involvement such as cough, tachypnea, or pulmonary infiltrates is often present.[24] Respiratory compromise may progress to adult respiratory distress syndrome (ARDS), especially in the elderly.[23]
  • Cardiac involvement is often minor and rare; however, cases of fatal myocarditis have been reported.[28] Infection with O tsutsugamushi may cause a relative bradycardia,[29] which, when combined with rash, may raise concern for typhoid fever.[6]
  • Scrub typhus may rarely cause acute renal failure, shock, and disseminated intravascular coagulation (DIC).[1]
Previous
Next

Causes

  • O tsutsugamushi
    • This is an obligate intracellular gram-negative bacterium that has a large number of serotypes. Five serotypes, Karp, Gilliam, Kawazaki, Boryon, and Kato, are helpful in serologic diagnosis.
    • This pathogen does not have a vacuolar membrane; thus, it freely grows in the cytoplasm of infected cells.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

David J Cennimo, MD, FACP, FAAP, AAHIVS  Assistant Professor of Medicine and Pediatrics, Adult and Pediatric Infectious Diseases, Co-Director Physician's Core, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

David J Cennimo, MD, FACP, FAAP, AAHIVS is a member of the following medical societies: American Academy of HIV Medicine, American Academy of Pediatrics, American College of Physicians, American Medical Association, HIV Medicine Association of America, Infectious Diseases Society of America, Medical Society of New Jersey, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Arry Dieudonne, MD  Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital

Arry Dieudonne, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

José Rafael Romero, MD  Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center

José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD  Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Aracelis D Fernandez, MD, FAAP, and Rosemary Johann-Liang, MD, to the original writing and development of this article.

References

  1. Watt G, Walker DH. Scrub typhus. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases Principles, Pathogens and Practice. Vol 1. 2nd ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2006:Chapter 52.

  2. Berman SJ, Kundim WD. Scrub Typhus in South Vietnam: A Study of 87 Cases. Annals Internal Med. July 1973;79:26-30.

  3. Corwin A, Soderquist R, Suwanabun N, Sattabongkot J, Martin L, Kelly D, et al. Scrub typhus and military operations in Indochina. Clin Infect Dis. Oct 1999;29(4):940-1. [Medline].

  4. Raoult D. Scrub typhus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. Vol 2. 6th ed. Philadelphia, PA: Elsever Churchill Livingstone; 2005:2309-10.

  5. Sharma PK, Ramakrishnan R, Hutin YJ, et al. Scrub typhus in Darjeeling, India: opportunities for simple, practical prevention measures. Trans R Soc Trop Med Hyg. Mar 13 2009;[Medline].

  6. Watt G, Chouriyagune C, Ruangweerayud R, Watcharapichat P, Phulsuksombati D, Jongsakul K, et al. Scrub typhus infections poorly responsive to antibiotics in northern Thailand. Lancet. Jul 13 1996;348(9020):86-9. [Medline].

  7. Watt G, Kantipong P, de Souza M, Chanbancherd P, Jongsakul K, Ruangweerayud R, et al. HIV-1 suppression during acute scrub-typhus infection. Lancet. Aug 5 2000;356(9228):475-9. [Medline].

  8. Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis. Oct 2003;16(5):429-36. [Medline].

  9. Ogawa M, Hagiwara T, Kishimoto T, Shiga S, Yoshida Y, Furuya Y. Scrub typhus in Japan: epidemiology and clinical features of cases reported in 1998. Am J Trop Med Hyg. Aug 2002;67(2):162-5. [Medline].

  10. Hendershot EF, Sexton DJ. Scrub typhus and rickettsial diseases in international travelers: a review. Curr Infect Dis Rep. Jan 2009;11(1):66-72. [Medline].

  11. Shirai A, Saunders JP, Dohany AL, et al. Transmission of Scrub Typhus to Human Volunteers by Laboratory Raised Chiggers. Jpn J Med Sci Biol. 1982;35(9).

  12. Suputtamongkol Y, Suttinont C, Niwatayakul K, et al. Epidemiology and clinical aspects of rickettsioses in Thailand. Ann N Y Acad Sci. May 2009;1166:172-9. [Medline].

  13. Jensenius M, Fournier PE, Raoult D. Rickettsioses and the international traveler. Clin Infect Dis. Nov 15 2004;39(10):1493-9. [Medline].

  14. Matsumura Y, Shimizu T. [Case of imported scrub typhus contracted in Myanmar]. Kansenshogaku Zasshi. May 2009;83(3):256-60. [Medline].

  15. Liu Y, Feng D, Suo J, et al. Clinical characteristics of the autumn-winter type scrub typhus cases in south of Shandong province, northern China. BMC Infect Dis. Jun 4 2009;9(1):82. [Medline].

  16. McGready R, Blacksell SD, Luksameetanasan R, et al. First Report of an Orientia tsutsugamushi Type TA716-Related Scrub Typhus Infection in Thailand. Vector Borne Zoonotic Dis. Jun 3 2009;[Medline].

  17. Sharma PK, Ramakrishnan R, Hutin YJ, et al. Scrub typhus in Darjeeling, India: opportunities for simple, practical prevention measures. Trans R Soc Trop Med Hyg. Mar 13 2009;[Medline].

  18. Kramme S, An le V, Khoa ND, et al. Orientia tsutsugamushi bacteremia and cytokine levels in Vietnamese scrub typhus patients. J Clin Microbiol. Mar 2009;47(3):586-9. [Medline].

  19. Brown GW, Robinson DM, Huxsoll DL, Ng TS, Lim KJ. Scrub typhus: a common cause of illness in indigenous populations. Trans R Soc Trop Med Hyg. 1976;70(5-6):444-8. [Medline].

  20. Brown GW, Robinson DM, Huxsoll DL. Serological evidence for a high incidence of transmission of Rickettsia tsutsugamushi in two Orang Asli settlements in Peninsular Malaysia. Am J Trop Med Hyg. Jan 1978;27(1 Pt 1):121-3. [Medline].

  21. Cao M, Guo H, Tang T, Wang C, Li X, Pan X, et al. Spring scrub typhus, People's Republic of China. Emerg Infect Dis. Sep 2006;12(9):1463-5. [Medline].

  22. Watt G, Jongsakul K, Chouriyagune C, Paris R. Differentiating dengue virus infection from scrub typhus in Thai adults with fever. Am J Trop Med Hyg. May 2003;68(5):536-8. [Medline].

  23. Wang CC, Liu SF, Liu JW, Chung YH, Su MC, Lin MC. Acute respiratory distress syndrome in scrub typhus. Am J Trop Med Hyg. Jun 2007;76(6):1148-52. [Medline].

  24. Chanta C, Chanta S. Clinical study of 20 children with scrub typhus at Chiang Rai Regional Hospital. J Med Assoc Thai. Dec 2005;88(12):1867-72. [Medline].

  25. Sirisanthana V, Puthanakit T, Sirisanthana T. Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J. Apr 2003;22(4):341-5. [Medline].

  26. Kim DM, Won KJ, Park CY, Yu KD, Kim HS, Yang TY. Distribution of eschars on the body of scrub typhus patients: a prospective study. Am J Trop Med Hyg. May 2007;76(5):806-9. [Medline].

  27. Edwards MS, Feigen RD. Rickettsial and Erlichial Diseases. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. Vol 2. 6th ed. Philadelphia, PA: Elsevier Saunders; 2009:2677-2678.

  28. Sittiwangkul R, Pongprot Y, Silviliarat S, Oberdorfer P, Jittamala P, Sirisanthana V. Acute fulminant myocarditis in scrub typhus. Ann Trop Paediatr. Jun 2008;28(2):149-54. [Medline].

  29. Aronoff DM, Watt G. Prevalence of relative bradycardia in Orientia tsutsugamushi infection. Am J Trop Med Hyg. Apr 2003;68(4):477-9. [Medline].

  30. Chanta C, Triratanapa K, Ratanasirichup P, Mahaprom W. Hepatic dysfunction in pediatric scrub typhus: role of liver function test in diagnosis and marker of disease severity. J Med Assoc Thai. Nov 2007;90(11):2366-9. [Medline].

  31. Phimda K, Hoontrakul S, Suttinont C, Chareonwat S, Losuwanaluk K, Chueasuwanchai S. Doxycycline versus azithromycin for treatment of leptospirosis and scrub typhus. Antimicrob Agents Chemother. Sep 2007;51(9):3259-63. [Medline].

  32. Phetsouvanh R, Blacksell SD, Jenjaroen K, Day NP, Newton PN. Comparison of indirect immunofluorescence assays for diagnosis of scrub typhus and murine typhus using venous blood and finger prick filter paper blood spots. Am J Trop Med Hyg. May 2009;80(5):837-40. [Medline].

  33. Paris DH, Aukkanit N, Jenjaroen K, Blacksell SD, Day NP. A highly sensitive quantitative real-time PCR assay based on the groEL gene of contemporary Thai strains of Orientia tsutsugamushi. Clin Microbiol Infect. May 2009;15(5):488-95. [Medline].

  34. Chen HC, Chang HC, Chang YC, Liu SF, Su MC, Huang KT, et al. Chest radiographic presentation in patients with scrub typhus. Trans R Soc Trop Med Hyg. Jan 2012;106(1):48-53. [Medline].

  35. Tsai CC, Lay CJ, Wang CL, Ho YH, Wang LS, Chen LK. Levofloxacin versus tetracycline antibiotics for the treatment of scrub typhus. Int J Infect Dis. Jun 3 2009;[Medline].

  36. Mathai E, Rolain JM, Verghese GM, Abraham OC, Mathai D, Mathai M. Outbreak of scrub typhus in southern India during the cooler months. Ann N Y Acad Sci. Jun 2003;990:359-64. [Medline].

  37. Kim YS, Lee HJ, Chang M, Son SK, Rhee YE, Shim SK. Scrub typhus during pregnancy and its treatment: a case series and review of the literature. Am J Trop Med Hyg. Nov 2006;75(5):955-9. [Medline].

  38. Watt G, Kantipong P, Jongsakul K, Watcharapichat P, Phulsuksombati D, Strickman D. Doxycycline and rifampicin for mild scrub-typhus infections in northern Thailand: a randomised trial. Lancet. Sep 23 2000;356(9235):1057-61. [Medline].

  39. Lee KY, Lee HS, Hong JH, Hur JK, Whang KT. Roxithromycin treatment of scrub typhus (tsutsugamushi disease) in children. Pediatr Infect Dis J. Feb 2003;22(2):130-3. [Medline].

  40. Olson JG, Bourgeois AL, Fang RC, Coolbaugh JC, Dennis DT. Prevention of scrub typhus. Prophylactic administration of doxycycline in a randomized double blind trial. Am J Trop Med Hyg. Sep 1980;29(5):989-97. [Medline].

 
Previous
Next
 
A transmission electron micrograph depicting a peritoneal mesothelial cell of a mouse that had been experimentally infected intraperitoneally with Orientia tsutsugamushi rickettsial micro-organisms. In this photomicrograph, several organisms are visible within the mesothelial cell's cytoplasm. O tsutsugamushi is the cause of scrub typhus.
Eschar on the neck.
Eschar on the scrotum.
Typical eschar.
Maculopapular rash.
Image of a chigger. Image taken from "Food and Environmental Hygiene Department" Web site and is reproduced under license from the Government of Hong Kong Special Administrative Region.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.