A 20 year girl was admitted in a private hospital in Vijayawada of Andhra Pradesh with high temperature, headache and vomiting. She was being treated for Typhoid by an RMP for the last ten days with no relief.
This prompted the parents to bring her to a private hospital. She was immediately admitted and tested positive for Scrub Typhus. Right diagnosis and timely treatment saved the young patient whose liver was already affected by the time she was admitted.
In the same hospital another 80 year old women is undergoing treatment for scrub typhus in intensive care. He has multiple organ dysfunctions and his condition is critical. According to unofficial sources, there might be five to ten cases of Scrub Typhus in Andhra Pradesh at present.
WHO listed Scrub Typhus as one of the Asia- pacific regions most under recognized, neglected and severe health problem. It is a fatal bacterial disease with acute febrile illness. It is caused by an intracellular gram negative bacterium, Orientia Tsutsugamushi.
It is transmitted to human beings through bite of infected mites belonging to family Trombiculidae. The larval stages of mites called chiggers act as vectors where as small rodents are the hosts.
Rats do not succumb to disease. Human being acts as an accidental host when the chiggers feeding upon the blood of rodents come in touch with humans. Larval chiggers are difficult to spot due to their small size of 0.3mm. The chigger bite is also not painful which makes it difficult to detect.
Rajasthan reported 510 cases of scrub typhus in August 2023 with 242 cases between august 4th to 11th in Jaipur alone. Last year 700 cases were reported from Rajasthan. This year a southern Odisha hospital reported 74 Scrub Typhus cases.
The Alapuzzha municipality issued medical alert for Srcub Typhus after 241 cases were reported in last two months. In 2022, Alipuzzha reported 180 cases and 136 in 2021. There have been four deaths in each year. Tests were conducted upon 1021 patients at Chettinad hospital of Kelambakam of Tamilnadu this year, out of them 93 patients tested positive for Scrub Typhus.
Cases have been on rise in the last five years in north eastern states of Mizoram and Manipur. During a study period from 2018-2022, 22914 cases of Scrub Typhus have been reported from Mizoram.
Aizwal was worst affected with 10580 cases. In the monsoon and post monsoon periods of 2022, there was an upsurge in cases with 6542 cases from Aizwal. In Andhra Pradesh, Laveru mandal, Appapuram village of Srikakulam reported four cases of Scrub Typhus in 2022 out of which two patients died.
Scrub typhus is spread throughout Asia Pacific regions what are known as Tsutsugamushi triangle, including Persian Gulf, northern Japan, northern Australia, China, Philippines and tropical Australia.
Nearly one million cases are reported every year from south and south East Asia with 10 % mortality. India has 25% disease load. CMC Vellore alone tests some 500- 1000 cases positive for Scrub Typhus every year.
The ideal environment for developing infections is grassy areas, bushes, river banks, forest clearings. The infectious mites often called chiggers transmit the disease from rats to human beings. Chiggers are mostly present in soil having scrub vegetation but also it’s not unusual to find chiggers in households.
It takes typically 10-12 days for the bacteria Orientia Tutsugamushi to develop symptoms of illness in human beings. Initially there is an asymptomatic stage where there are no symptoms for one week to ten days. Early symptoms include headache, high fever, dry cough, red eyes, muscle pains, rashes, and knots around neck, groin or armpits.
The most distinguishing symptom is known to be a blackish necrotic lesion called Escher, at spot of mite bite. It resembles a cigarette burnt. But it has been observed that Escher is not being seen in most of the cases in Indian subcontinent. Scrub typhus without Escher is a febrile illness without any evidence of localization, hence called acute undifferentiated illness.
Hence it is clinically indistinguishable from malaria, dengue and other fevers. In the second week, it invades kidneys, liver, lungs and brain with prominent multiple organ dysfunction, confusion and coma are also seen. Acute renal failure and respiratory disorders are seen. Without treatment, it becomes dangerous in the later stage with mortality rate of 7-30%.
Treatment is very easy and affective with combination therapy of doxycyclin and azithromycin. Patients respond very well to the treatment and recovery rate is very high. But the problem is the failure of early diagnosis and lack of knowledge about this bacterial disease.
This is highly difficult to identify clinically from other acute febrile infections such as typhoid, malaria and dengue due to common symptoms and paucity of lesions or eschers in Indian population. ELISA and PCR tests are affective to diagnose the disease.
These tests are available only at the district level hospitals. Most of the cases have been reported from rural and forest areas where tests are not available. RMP’s and local doctors often mistake it with other seasonal illnesses such as typhoid and dengue. Lot of time is lost with incorrect diagnosis and improper treatment, during which the sickness can turn fatal.
It is surprising that cases have been reported in urban areas also where the mites have a chance to come in touch with human beings. Monsoon and post monsoon seasons have seen a surge in cases because of overgrown vegetation.
Scrub Tyhus can be prevented by vector and host control. Chiggers or mites are the vectors and rats are the host. It is possible to prevent Srub Typhus by preventing contact with mites.
Care should be taken to control the shrubs and weeds in monsoon. Outdoor workers in rural areas should be careful to cover their legs and hands while working in grass. Mite repellents should be used and rodent population should be kept under check.
Early diagnosis can bring down complications and fatality rates. There is lack of statistical information and significant knowledge gap about this neglected illness which makes it difficult to deal with it. When patients suffer with unabated high temperature combined with severe headache for more than three days, it’s better to consult an experienced doctor who can diagnose properly and give timely treatment.