Hemothorax in scrub typhus: A rare clinical manifestation

Roshini Roberts; Nayyar Iqbal; Sudhagar Mookkappan; Ishan Chavada

doi:10.4103/2455-3069.198380

CASE REPORT

Year : 2016 | Volume : 2 | Issue : 2 | Page : 129-131

Hemothorax in scrub typhus: A rare clinical manifestation

Roshini Roberts, Nayyar Iqbal, Sudhagar Mookkappan, Ishan Chavada
Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission	04-Oct-2016
Date of Acceptance	18-Nov-2016
Date of Web Publication	13-Jan-2017

Correspondence Address:
Nayyar Iqbal
Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2455-3069.198380

Abstract

Scrub typhus is one of the most common causes of acute febrile illness in South India. The clinical features vary from mild illness to severe complications such as gastrointestinal bleed, acute respiratory distress syndrome, meningoencephalitis, and acute kidney injury. The pathological findings are characterized by vasculitis of small vessels of the involved organs. We report probably the first case of scrub typhus-related hemothorax in a 72-year-old diabetic male who presented with acute febrile illness with shortness of breath and acute kidney injury. The patient improved with azithromycin and hemodialysis.

Keywords: Acute kidney injury, hemothorax, scrub typhus

How to cite this article:
Roberts R, Iqbal N, Mookkappan S, Chavada I. Hemothorax in scrub typhus: A rare clinical manifestation. J Curr Res Sci Med 2016;2:129-31

How to cite this URL:
Roberts R, Iqbal N, Mookkappan S, Chavada I. Hemothorax in scrub typhus: A rare clinical manifestation. J Curr Res Sci Med [serial online] 2016 [cited 2023 May 29];2:129-31. Available from: https://www.jcrsmed.org/text.asp?2016/2/2/129/198380

Introduction

Scrub typhus is caused by a Gram-negative bacterium Orientia tsutsugamushi, family Rickettsiaceae. It is a zoonotic infection transmitted to humans by the bite of the larval form of trombiculid mite called chiggers.^[1] It is endemic to Southeast Asian countries extending from Japan in the East to Pakistan in the West and Russia in the North to Australia in the South.^[2] It is also prevalent in many parts of India with outbreaks being reported from Puducherry.^[3]

It has an incubation period of 6–21 days after the bite of trombiculid mite.^[2] The clinical features of this disease range from nonspecific symptoms such as anorexia, fatigue, myalgia, headache, and fever to fatal complications such as acute respiratory distress syndrome (ARDS), meningoencephalitis, myocarditis, acute renal failure, hepatitis, and shock. The pathognomonic feature of this illness is an eschar and lymphadenopathy.^[4]

Case Report

A 72-year-old diabetic male presented with a 1-week history of continuous high-grade fever and dry cough. On examination, he was conscious and oriented. He was febrile (39°C) with a pulse rate of 142 bpm, blood pressure of 130/70 mmHg, and respiratory rate of 23 breaths/min with oxygen saturation of 90% on room air. There were no rashes, lymphadenopathy, icterus, or eschar. Systemic examination revealed decreased breath sounds in bilateral infra-axillary and subscapular regions. Examination of other systems was found to be normal. His investigations showed thrombocytopenia, anemia with mild leukocytosis, elevated transaminases, hypoalbuminemia, and deranged renal function [Table 1]. His chest radiograph showed bilateral obliteration of costophrenic angles, more on the right side [Figure 1]. His electrocardiogram and two-dimensional echocardiography were normal.

Table 1: Laboratory investigations on admission and discharge

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Figure 1: Radiological picture of bilateral pleural effusion more on the right sides

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In view of multisystem involvement, tropical fever workup was done. Dengue serology, serum Widal, Leptospira IgM antibodies, and malarial antigen were all negative except for scrub IgM antibodies. His urine and blood cultures were sterile.

Pleural aspirate was hemorrhagic, and analysis revealed red blood cells of 2 million, hematocrit of 19%, (serum hematocrit to pleural fluid hematocrit was >50%), lactate dehydrogenase of 465 U/L, protein of 309 mg/dl, and adenosine deaminase of 20 IU/L. His pleural fluid acid-fast bacilli and culture were negative as was tuberculosis-polymerase chain reaction (PCR) [Table 1]. Scrub typhus PCR was not done due to financial constraints. In view of scrub typhus, the patient was started on tablet azithromycin 500 mg once daily along with the hemodialysis. He responded well to the treatment. He was discharged after 10 days of azithromycin and 5 sessions of hemodialysis.

On follow-up 1 month after discharge, the patient's renal functions and thrombocyte count had normalized, and chest X-ray findings had also considerably improved [Table 1] and [Figure 2].

Figure 2: Follow-up chest X-ray after 1 month showing resolution of hemothorax

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Discussion

Scrub typhus is an important differential diagnosis for acute febrile illness occurring in the tropics.^[2] Dengue fever, malaria, typhoid, and leptospirosis have very similar clinical presentations to scrub typhus, and these have been clubbed together as the “Tropical Fever Syndrome.”^[5]

With the bite of a trombiculid mite,^[4] the bacterium, O. tsutsugamushi multiplies at the site of inoculation leading to necrosis and formation of an eschar with regional lymphadenopathy. Involvement of the vascular endothelium of several organs systems, such as skin, liver, brain, kidney, meninges, gastrointestinal system, and lung, contributes to pathophysiology and clinical manifestations arising from vasculitis.^[6],[7]

Although an eschar is said to be a pathognomic feature, it is present in only 50% of patients.^[2]

A study by Kim et al.^[8] concluded that the absence of eschar was a significant factor contributing to the possibility of potential complications in scrub typhus. The other factors for increased severity were age ≥60 years, white blood cell counts >10,000/mm ³, and serum albumin ≤3.0 g/dL. According to the above criteria, our patient had severe form of scrub typhus.

Multi-organ dysfunction is common in severe scrub typhus infection. In a study among patients admitted to an Intensive Care Unit with severe scrub typhus infection,^[9] 99% had dysfunction of 3 or more organs, with respiratory dysfunction being the most predominant (96.6%) and renal dysfunction occurring in 63.8% of patients, both of which were seen in our patient. Pulmonary manifestations in scrub typhus vary from bronchitis, interstitial pneumonitis progressing to ARDS.^{[10],[11],[12]}

Immunologic mechanism apart from vasculitis due to direct invasion of the rickettsial organism is involved in the pathogenesis of pulmonary involvement of scrub typhus as suggested by Park et al.^[13] The chest abnormalities of scrub typhus reported in literature are interstitial pneumonia (51.4%), pleural effusion (42.6%), cardiomegaly (37.6%), pulmonary alveolar edema (20.8%), hilar adenopathy (13.8%), and focal atelectasis (11.8%).^[14]

In a study by Kim et al.,^[15] 21% of the patient of scrub typhus had pleural effusion. Old age, male gender, low serum albumin, and heart failure were associated with an increased incidence of pleural effusion among scrub typhus patients. Eighty-eight percent of the patient had bilateral pleural effusion. In the above study, 12% of the patients had exudative pleural effusion, and none of the patients had hemothorax.

The causes of hemothorax are trauma, coagulopathy, iatrogenic while inserting a central venous catheter, arteriovenous malformations, connective tissue disorders, mesothelioma, lung malignancy, etc.^[16] It has also been reported in patients undergoing hemodialysis.^[17] Hemothorax is defined as pleural fluid hematocrit >50% of blood. Since our patient did not have any of the known causes of hemothorax, his condition may be attributed to scrub typhus infection.^[16]

Elevated transaminases (aspartate transaminase > alanine transaminase) along with thrombocytopenia and leukocytosis have been described in the literature.^[2] Although our patient had thrombocytopenia, his coagulation profile was normal, so the possibility of hemothorax arising due to a coagulopathy seems remote. Bleeding manifestations in scrub typhus have already been described in literature. The most common site is upper gastrointestinal tract ^[2] although hemoperitoneum ^[18] and small bowel bleeds ^[2] have also been reported. A rare manifestation of hemorrhagic transformation of scrub typhus encephalitis ^[19] has been reported earlier. Hemothorax in scrub typhus has not been reported in the past.

He responded well to treatment, and his pleural effusion, thrombocytopenia, and renal function improved to normal.

Conclusion

The myriad clinical presentations of scrub typhus mimic various diseases, and this makes it difficult to diagnose early. Rare presentations such as a hemothorax following an acute febrile illness in endemic areas should prompt the physician to investigate and treat for scrub typhus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Sankuratri S, Kalagara P, Samala KB, Veledandi PK, Atiketi SB. Scrub typhus with acute respiratory distress syndrome (ARDS) and its management in Intensive Care Unit: A case report. J Clin Diagn Res 2015;9:OD10-1.
2.	Iqbal N, Titus S, Basheer A, George S, George S, Mookkappan S, et al. Polyarthritis and massive small bowel bleed: An unusual combination in scrub typhus. Australas Med J 2015;8:89-95.
3.	Vivekanandan M, Mani A, Priya YS, Singh AP, Jayakumar S, Purty S. Outbreak of scrub typhus in Pondicherry. J Assoc Physicians India 2010;58:24-8.
4.	Saxena A, Khiangte B, Tiewsoh I. Scrub typhus complicated by acute respiratory distress syndrome and multiorgan failure; an unrecognized alarming entity in central India: A report of two cases. J Family Med Prim Care 2014;3:80-3. [PUBMED]
5.	Rungta N. Scrub typhus: Emerging cause of multiorgan dysfunction. Indian J Crit Care Med 2014;18:489-91. [PUBMED]
6.	Dogra S. Recent advances in understanding pathophysiology of scrub typhus. JK Sci 2010;12:70-1.
7.	Settle E, Pinkerton H, Corbett A. A pathologic study of tsutsugamushi disease (scrub typhus) with notes on clinicopathologic correlation. J Lab Clin Med 1945;30:639.
8.	Kim DM, Kim SW, Choi SH, Yun NR. Clinical and laboratory findings associated with severe scrub typhus. BMC Infect Dis 2010;10:108.
9.	Peter J, Karthik G, Kalki R, Chrispal A, Pichamuthu K, Iyyadurai R, et al. Profile of organ dysfunction and predictors of mortality in severe scrub typhus infection requiring intensive care admission. Indian J Crit Care Med 2014;18:497. [PUBMED]
10.	Chayakul P, Panich V, Silpapojakul K. Scrub typhus pneumonitis: An entity which is frequently missed. Q J Med 1988;68:595-602.
11.	Strickman D, Smith CD, Corcoran KD, Ngampochjana M, Watcharapichat P, Phulsuksombati D, et al. Pathology of Rickettsia tsutsugamushi infection in Bandicota savilei, a natural host in Thailand. Am J Trop Med Hyg 1994;51:416-23.
12.	Song SW, Kim KT, Ku YM, Park SH, Kim YS, Lee DG, et al. Clinical role of interstitial pneumonia in patients with scrub typhus: A possible marker of disease severity. J Korean Med Sci 2004;19:668-73.
13.	Park JS, Jee YK, Lee KY, Kim KY, Myong NH, Seo PW. Acute respiratory distress syndrome associated with scrub typhus: Diffuse alveolar damage without pulmonary vasculitis. J Korean Med Sci 2000;15:343-5.
14.	Jeong YJ, Kim S, Wook YD, Lee JW, Kim KI, Lee SH. Scrub typhus: Clinical, pathologic, and imaging findings. Radiographics 2007;27:161-72.
15.	Kim HH, Chung JH, Kim DM, Yun NR, Lee J, Kwon YE, et al. The clinical characteristics of pleural effusion in scrub typhus. BMC Infect Dis 2016;16:278.
16.	Patrini D, Panagiotopoulos N, Pararajasingham J, Gvinianidze L, Iqbal Y, Lawrence DR. Etiology and management of spontaneous haemothorax. J Thorac Dis 2015;7:520-6.
17.	Varan B, Karakayali H, Kutsal A, Ozdemir N. Spontaneous hemothorax in a hemodialysis patient. Pediatr Nephrol 1998;12:65-6.
18.	Lin WY, Lin GM, Chang FY. An unusual presentation of scrub typhus with atraumatic hemoperitoneum. Am J Gastroenterol 2009;104:1067.
19.	Kim HC, Yoon KW, Yoo DS, Cho CS. Hemorrhagic transformation of scrub typhus encephalitis: A rare entity. Clin Neuroradiol 2015;25:415-8.