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LETTER TO THE EDITOR
Year : 2013  |  Volume : 16  |  Issue : 1  |  Page : 131
 

Neurological manifestations of scrub typhus


1 Department of Internal Medicine, St Stephens Hospital, Delhi, India
2 Department of Paediatrics, Lady Hardinge Medical College, Delhi, India

Date of Web Publication25-Feb-2013

Correspondence Address:
Sameer Gulati
Department of Internal Medicine, St. Stephens Hospital, Delhi - 54
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.107701

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How to cite this article:
Gulati S, Maheshwari A. Neurological manifestations of scrub typhus. Ann Indian Acad Neurol 2013;16:131

How to cite this URL:
Gulati S, Maheshwari A. Neurological manifestations of scrub typhus. Ann Indian Acad Neurol [serial online] 2013 [cited 2018 Jan 19];16:131. Available from: http://www.annalsofian.org/text.asp?2013/16/1/131/107701


Sir,

We read the article "First case of scrub typhus with meningoencephalitis from Kerala: An emerging infectious threat" by Saifudheen et al.[1] with great interest. As stressed by the authors, scrub typhus is rampant in northern, eastern, and southern India. Apart from these regions, recently it has also been reported from central India. [2] Because of wide geographic presence in India, sensitizing clinicians regarding varied presentations of this disease is very important. Besides, it is difficult to differentiate scrub typhus from other dengue fever like illnesses, especially after rains. [3] It is imperative to differentiate scrub typhus from other febrile illnesses and to start specific treatment at the earliest to decrease morbidity and mortality. Recognizing the full spectrum of clinical manifestations can help clinicians in considering appropriate differential diagnosis amongst the dengue fever like illnesses.

The authors have described two cases of meningoencephalitis due to scrub typhus in the present article. They have mentioned that seizures, delirium, cerebellitis, myelitis, cerebral hemorrhage, and hearing loss are the other neurological presentations of this infectious disease. In order to identify the whole spectrum of neurological manifestations of scrub typhus, we searched the PubMed to look for case reports/case series in this regard. We found various afflictions other than those mentioned in this article.

Meningoencephalitis due to scrub typhus usually presents without any focal neurological signs. However, focal neurological signs such as bilateral sixth and seventh nerve palsies have also been described. [4] Isolated abducens (VI) nerve palsy has been reported 2 days after initiation of treatment for scrub typhus. [5] Another report mentions development of bilateral simultaneous facial nerve palsy in convalescent period, which improved on administration of steroids. [6] Scrub typhus associated with opsoclonus, transient  Parkinsonism More Details, and myoclonus has been observed. [7],[8] A patient of scrub typhus with pain indistinguishable from trigeminal neuralgia was reported, who improved clinically after treatment. [9] An isolated case report of brachial plexus neuropathy with scrub typhus who improved on treatment also finds a place in literature. [10] One female patient presented with Guillain-Barre syndrome 2 weeks after receiving treatment for scrub typhus. [11] Polyneuropathy along with cerebral infarction has been recognized as a neurological complication of scrub typhus. [12] Acute disseminated encephalomyelitis is yet another dreadful neurological complication of scrub typhus. [13] Chung et al., have demonstrated persistence of viable Orientia tsutsugamushi in patients 1-18 months after recovery from scrub typhus. Interestingly, one of these patients suffered from transient ischemic attack 8 months later. [14] Though no conclusions can be drawn from this, patients with risk factors for atherosclerosis and scrub typhus should be followed up for long term.

To conclude, scrub typhus may present with a wide spectrum of neurological manifestations. Knowledge of these manifestations will enable clinicians to consider scrub typhus as one of the differential diagnosis of acute febrile illnesses with neurological involvement.

 
   References Top

1.Saifudheen K, Kumar KG, Jose J, Veena V, Gafoor VA. First case of scrub typhus with meningoencephalitis from Kerala: An emerging infectious threat. Ann Indian Acad Neurol 2012;15:141-4.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Rathi NB, Rathi AN, Goodman MH, Aghai ZH. Rickettsial diseases in Central India: Proposed clinical scoring system for early detection of spotted fever. Indian Pediatr 2011;48:867-72.  Back to cited text no. 2
[PUBMED]    
3.Gulati S, Maheshwari A. Dengue fever like illnesses - How different are they from each other? Scand J Infect Dis 2012;44:522-30.  Back to cited text no. 3
[PUBMED]    
4.Kim DE, Lee SH, Park KI, Chang KH, Roh JK. Scrub typhus encephalomyelitis with prominent focal neurological signs. Arch Neurol 2000;57:1770-2.  Back to cited text no. 4
[PUBMED]    
5.Lee YH, Yun YJ, Jeong SH. Isolated abducens nerve palsy in a patient with scrub typhus. J AAPOS 2010;14:460-1.  Back to cited text no. 5
[PUBMED]    
6.Lin WR, Chen TC, Lin CY, Lu PL, Chen YH. Bilateral simultaneous facial palsy following scrub typhus meningitis: A case report and literature review. Kaohsiung J Med Sci 2011;27:573-6.  Back to cited text no. 6
[PUBMED]    
7.Chiou YH, Yang CJ, Lai TH. Scrub typhus associated with transient parkinsonism and myoclonus. J Clin Neurosc 2012  Back to cited text no. 7
    
8.Nam TS, Choi SM, Park KH, Kim MK, Cho KH, Opsoclonus associated with scrub typhus. Neurology 2010;74:1925.  Back to cited text no. 8
    
9.Arai M, Nakamura A, Shichi D. Case of tsutsugamushi disease (scrub typhus) presenting with fever and pain indistinguishable from trigeminal neuralgia. Rinsho Shinkeigaku 2007;47:362-4.  Back to cited text no. 9
[PUBMED]    
10.Ting KS, Lin JC, Chang MK. Brachial plexus neuropathy associated with scrub typhus: Report of a case. J Formos Med Assoc 1992;91:110-2.  Back to cited text no. 10
[PUBMED]    
11.Lee SH, Jung SI, Park KH, Choi SM, Park MS, Kim BC, et al. Guillain-Barré syndrome associated with scrub typhus. Scand J Infect Dis 2007;39:826-8.  Back to cited text no. 11
    
12.Kim JH, Lee SA, Ahn TB, Yoon SS, Park KC, Chang DI, et al. Polyneuropathy and cerebral infarction complicating scrub typhus. J Clin Neurol 2008;4:36-9.  Back to cited text no. 12
    
13.Chen PH, Hung KH, Cheng SJ, Hsu KN. Scrub typhus associated acute disseminated encephalomyelitis. Acta Neurol Taiwan 2006;15:251-4.  Back to cited text no. 13
    
14.Chung MH, Lee JS, Baek JH, Kim M, Kang JS. Persistence of Orientia tsutsugamushi in humans. J Korean Med Sci 2012;27:231-5.  Back to cited text no. 14
    



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