Edit concept Question Editor Create issue ticket

Tsutsugamushi Disease

Scrub Typhus

Tsutsugamushi disease or scrub typhus is a parasitic infection caused by a parasite, Orientia tsutsugamushi, carried by mites. It presents with fever, headache, a macular rash, lymphadenopathy and eschar at the region of the mite bite.


Presentation

Tsutsugamushi disease is transmitted through a mite bite. During the inoculation period, which typically lasts for 6 to 20 days, the patient usually remains asymptomatic. Approximately at the tenth day following the initial infection, high fever, headaches, myalgia and fatigue emerge. The non-specificity of the symptoms constitutes a diagnostic obstacle at the early disease phase. During this initial period, a papule begins to form at the region of the mite bite, gradually progressing to form a necrotic localized spot, referred to as an eschar.

Despite the diagnostic challenge due to the non-specificity of the symptoms, the existence of an eschar is pathognomonic of tsutsugamushi disease; it is observed in half of the patients with a primary infection and is well-defined by the time that an individual develops fever [1] [2] [3]. Other symptoms associated with tsutsugamushi disease are lymphadenopathy, regional or generalized, ocular pain, a productive cough and infected conjunctiva [4] [5]. A characteristic symptom is also the centrifugal macular rash that appears after approximately a week following the infection. The erythema develops on the torso, may gradually assume papular characteristics and may not be observed due to its transient nature [6].

As the disease progresses, pneumonia, encephalitis, delirium and splenomegaly may be added to the clinical picture.

Generalized Lymphadenopathy
  • All five children had fever, vomiting and generalized lymphadenopathy, but none had eschar or rash. One was cured with doxycycline, remaining four patients treated with azithromycin and one died despite treatment.[ncbi.nlm.nih.gov]
  • After an incubation period of 6 to 21 days (mean 10 to 12 days), symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy.[merckmanuals.com]
  • The bacteria multiply at the inoculation site, and a papule forms that ulcerates and becomes necrotic, evolving into an eschar, with regional lymphadenopathy that may progress to generalized lymphadenopathy within a few days.[emedicine.com]
Splenomegaly
  • As the disease progresses, pneumonia, encephalitis, delirium and splenomegaly may be added to the clinical picture.[symptoma.com]
  • As the eschar heals, there is a sudden onset of headache, malaise, anorexia, weakness, and fever, followed by pneumonia, a macular rash (on the trunk before the limbs), lymphadenopathy, hepato-splenomegaly, and conjunctivitis.[histopathology-india.net]
  • Splenomegaly may be present, and interstitial myocarditis is more common than in other rickettsial diseases. In untreated patients, high fever may persist 2 week, then falls gradually over several days.[merckmanuals.com]
  • Morbilliform rash, eschar, splenomegaly, and lymphadenopathies are typical signs. Leukopenia and abnormal liver function tests are commonly seen in the early phase of the illness.[en.wikipedia.org]
  • Plasma fibrinogen was normal at 312 mg/dL (normal 160–380) and fibrinogen degradation products were slightly elevated at 11.4 μg/mL ( 7 cells (normal Computed tomography revealed mild splenomegaly and small pleural effusion bilaterally, but no significant[tandfonline.com]
Fever
  • […] or leptospirosis infection; the latter is known to often coexist with scrub fever.[symptoma.com]
  • […] patients given doxycycline monotherapy (fever clearance time 52 h).[ncbi.nlm.nih.gov]
  • The disease was also a problem for US troops stationed in Japan after WWII, and was variously known as "Shichitō fever" (by troops stationed in the Izu Seven Islands) or "Hatsuka fever" (Chiba prefecture).[en.wikipedia.org]
  • Of the numerous tick-borne rickettsioses identified in recent years, African tick-bite fever appears to be of particular importance to travellers. The newly described flea-borne spotted fever caused by Rickettsia felis may be global in distribution.[doi.org]
High Fever
  • Tsutsugamushi disease is characterized by the early appearance of a black crust at the bitten area and the subsequent development of macular or macropapular rush on the whole body with high fever.[ncbi.nlm.nih.gov]
  • Approximately at the tenth day following the initial infection, high fever, headaches, myalgia and fatigue emerge. The non-specificity of the symptoms constitutes a diagnostic obstacle at the early disease phase.[symptoma.com]
  • It features headache, high fever and a rash.[medical-dictionary.thefreedictionary.com]
Chills
  • Case report of a 60-year-old woman who complained of fever, chills, headache, lymphadenopathy, and blurred vision in the right eye following an insect bite to the lower right forehead.[ncbi.nlm.nih.gov]
  • After an incubation period of 6 to 21 days (mean 10 to 12 days), symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy.[merckmanuals.com]
  • A reddish or pinkish lesion appears at the site of the mite bite, and the person begins to experience headache, fever, chills, and general pains, along with swollen lymph glands.[britannica.com]
  • Patient 2 In January 2016, a 40-year-old construction worker had sudden onset of high fever, chills, night sweats, headaches, myalgia, retro-orbital pain, and photophobia.[nejm.org]
Malaise
  • As the eschar heals, there is a sudden onset of headache, malaise, anorexia, weakness, and fever, followed by pneumonia, a macular rash (on the trunk before the limbs), lymphadenopathy, hepato-splenomegaly, and conjunctivitis.[histopathology-india.net]
  • She also complained of malaise, loss of appetite, and dyspnea. Central nervous system symptoms such as headache and confusion were not observed.[tandfonline.com]
  • Signs and symptoms include sudden headache, generalized muscle pain, malaise, and macular skin lesions. The infection may affect the central nervous system causing encephalitis.[fpnotebook.com]
  • Increasing malaise and confusion led to hospitalization; at presentation, she was febrile (body temperature, 40.0 C) and apathetic.[nejm.org]
Vietnamese
  • Orientia tsutsugamushi bacteremia and cytokine levels in Vietnamese scrub typhus patients. J Clin Microbiol. 2009 Mar. 47(3):586-9. [Medline]. [Full Text]. Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM.[emedicine.com]
Painful Cough
  • Signs and symptoms include fever, headache, muscle pain, cough, and gastrointestinal symptoms. More virulent strains of O. tsutsugamushi can cause hemorrhaging and intravascular coagulation.[en.wikipedia.org]
Severe Clinical Course
  • The precise mechanism underlying the more severe clinical course of JSF is not fully understood.[ncbi.nlm.nih.gov]
Severe Clinical Course
  • The precise mechanism underlying the more severe clinical course of JSF is not fully understood.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Gastrointestinal signs included hepatomegaly, jaundice and abdominal pain. Since multiple serotypes exist and cross-immunity is transient, recurrent infections are common.[histopathology-india.net]
  • Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself[nejm.org]
  • An episode of transient abdominal pain accompanied by vaginal bleeding occurred on the third hospital day.[doi.org]
  • Other signs and symptoms include: rash, lymphadenopathy, hepatosplenomegaly, cough, sore throat, abdominal pain, and central nervous system involvement.[kjim.org]
  • The common symptoms noted were fever (68/68, 100%), myalgia (20/68, 29.41%), vomiting (8/68, 11.76%), abdominal pain (10/68, 14.71%), chills (11/68, 16.17%), rigors, and headache (9/68, 13.23%) cases.[ijpmonline.org]
Acute Abdomen
  • Unusual presentation of acute abdomen in scrub typhus: a report of two cases. Zhonghua Yi Xue Za Zhi (Taipei) 1995; 55: 401–404. PubMed Google Scholar 12. Pai H, Sohn S, Seong Y et al.[doi.org]
Blurred Vision
  • Case report of a 60-year-old woman who complained of fever, chills, headache, lymphadenopathy, and blurred vision in the right eye following an insect bite to the lower right forehead.[ncbi.nlm.nih.gov]
Retinal Hemorrhage
  • To report branch retinal vein occlusion and retinal hemorrhages associated with tsutsugamushi disease.[ncbi.nlm.nih.gov]
Flame-shaped Hemorrhage
  • Ophthalmologic examination disclosed bilateral conjunctival injection, flame-shaped hemorrhage in her right fundus, and scattered hemorrhage in her left fundus. Fluorescein angiography demonstrated dye leakage and dilation of capillaries.[ncbi.nlm.nih.gov]
Otalgia
  • Otalgia and eschar in the external auditory canal in scrub typhus complicated by acute respiratory distress syndrome and multiple organ failure. BMC Infect Dis. 2011 Mar 30. 11:79. [Medline]. [Full Text]. Edwards MS, Feigen RD.[emedicine.com]
Exanthema
  • ‘The tsutsugamushi disease is contracted by high temperature, exanthema and adenopathy following the cold-like symptoms.’[en.oxforddictionaries.com]
  • Patient 1 In January 2015, a 38-year-old homemaker was hospitalized with fever and generalized exanthema.[nejm.org]
Pruritic Rash
  • Two weeks earlier, she had noticed a transient pruritic rash on her abdomen, which had appeared after she had been collecting firewood in a local forest clearing.[nejm.org]
Pruritic Rash
  • Two weeks earlier, she had noticed a transient pruritic rash on her abdomen, which had appeared after she had been collecting firewood in a local forest clearing.[nejm.org]
Night Sweats
  • Patient 2 In January 2016, a 40-year-old construction worker had sudden onset of high fever, chills, night sweats, headaches, myalgia, retro-orbital pain, and photophobia.[nejm.org]
Withdrawn
  • During the first year of treatment, the combined regimen was withdrawn because of lack of efficacy and the regimen was replaced with 900 mg rifampicin (n 37).[ncbi.nlm.nih.gov]
Headache
  • It presents with fever, headache, a macular rash, lymphadenopathy and eschar at the region of the mite bite. Tsutsugamushi disease is transmitted through a mite bite.[symptoma.com]
  • Case report of a 60-year-old woman who complained of fever, chills, headache, lymphadenopathy, and blurred vision in the right eye following an insect bite to the lower right forehead.[ncbi.nlm.nih.gov]
  • After an incubation period of 6 to 21 days (mean 10 to 12 days), symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy.[merckmanuals.com]
  • Tsutsugamushi disease: A mite-borne infectious disease caused by a microorganism, Rickettsia tsutsugamushi, characteristically with fever, headache, a raised (macular) rash, swollen glands (lymphadenopathy) and a dark crusted ulcer (called an eschar or[medicinenet.com]
  • It features headache, high fever and a rash.[medical-dictionary.thefreedictionary.com]

Workup

The complete workup for scrub typhus encompasses a multitude of tests and procedures, including routine blood tests, serology, and PCR.

More specifically, laboratory blood tests including a complete blood count and biochemical studies usually yield the following results:

The aforementioned findings may also suggest a potential dengue fever or leptospirosis infection; the latter is known to often coexist with scrub fever [8].

Serologic tests are further carried out, as they constitute the primary diagnostic procedures. A direct immunoperoxidase test and an immunofluorescent assay are used to establish the diagnosis and are expected to yield a result displaying a 4-fold augmentation of antibody titers between acute and convalescent serum specimens [9]. All potential O. tsutsugamushi subtypes should be considered as a possibility and should, therefore, be separately investigated serologically. A dot immunoassay can also be employed in order to diagnose tsutsugamushi disease, whereas the immunochromatographic test, aimed at the detection of immunoglobulin (Ig) M and IgG antibodies exhibit a considerably greater sensitivity for an early diagnosis when compared to the standard immunofluorescence assay.

The polymerase chain reaction tests (PCR) has proven a valuable diagnostic tool, on eschar samples, early in the course of the disease. In third world countries, the method of choice is the Weil-Felix OX-K strain agglutination reaction; when more advanced medical facilities are available, this test is not opted for due to its decreased sensitivity.

Pericardial Effusion
  • Pericardial effusion in Tsutsugamushi Disease is not a common manifestation, although a high rate of effusion was reported in autopsy in those who had died of the disease.[ncbi.nlm.nih.gov]
Rickettsia Orientalis
  • Tsutsugamushi, which is caused by Rickettsia nipponica (Rickettsia orientalis, Rickettsia tsutsugamushi), is widely distributed over an area which includes Japan, Malaya, French Indo-China, Sumatra, the Philippines, other islands of the Pacific and northern[jamanetwork.com]
  • The cross-protection test with mice for identification and differentiation of several strains of Rickettsia orientalis newly isolated in Japan. Jpn J Med Sci Biol 1959;12:391–404.[synapse.koreamed.org]
  • Strain variation of Rickettsia orientalis in the complement fixation test. Jpn J Med Sci Biol. 1964;17:59–72. View Article PubMed Google Scholar Nakayama K, Yamashita A, Kurokawa K, Morimoto T, Ogawa M, Fukuhara M.[bmcinfectdis.biomedcentral.com]

Treatment

  • The clinical response to doxycycline treatment in patients with early, mild scrub typhus in northern Thailand was compared with the results of treatment in Mae Sod, western Thailand.[ncbi.nlm.nih.gov]
  • The distributions of prior antimicrobial treatment were similar in the two treatment groups (data not shown here).[doi.org]

Prognosis

  • Prognosis Prognosis varies and depends on the severity of illness, which relates to the different strains of O tsutsugamushi, as well as to host factors. Severe disease is uncommon with antimicrobial treatment.[emedicine.com]

Etiology

  • To retrospectively confirm the suspected rickettsial disease (Scrub typhus) using a gold standard diagnostic test i.e. microimmunofluorescence in pediatric patients with acute febrile illness of unknown etiology.[ncbi.nlm.nih.gov]
  • The etiologic agent of scrub typhus, R. tsutsugamushi, is a natural infection of several trombiculid mites, most commonly L. deliensis.[cambridge.org]
  • A number of microorganisms were hypothesized as an etiology of the illness. This is the first reported case of Kawasaki disease with tsutsugamushi disease.[circ.ahajournals.org]
  • Brief First Online: 15 November 2008 Abstract To retrospectively confirm the suspected rickettsial disease (Scrub typhus) using a gold standard diagnostic test i.e. microimmunofluorescence in pediatric patients with acute febrile illness of unknown etiology[doi.org]

Epidemiology

  • The current system for Tsutsugamushi disease surveillance is useful for describing epidemiologic patterns by time, prefecture, and demographic characteristics.[ncbi.nlm.nih.gov]
  • Short Communication Comparative Research on Epidemiological Aspects of Tsutsugamushi Disease (Scrub Typhus) between Korea and Japan Hyeong-Ae Bang, Myeong-Jin Lee 1 and Won-Chang Lee 2 * Faculty of Public Health, The Korean Public Health Association;[web.archive.org]
  • Numerous experts in medicine, epidemiology, and entomology were called upon to examine the problem, and, two major lines of defense against the disease had been developed.[cambridge.org]
Sex distribution
Age distribution

Pathophysiology

  • Scrub typhus: pathophysiology, clinical manifestations and prognosis. Asian Pac J Trop Med. 2012 Apr. 5(4):261-4. [Medline]. Watt G, Jongsakul K, Chouriyagune C, Paris R.[emedicine.com]

Prevention

  • The net benefit should increase if the tsutsugamushi disease prevention program is continued and the implementation period is expanded to 10 years.[ncbi.nlm.nih.gov]
  • This study shows the status of scrub typhus in Japan in 1998 and provides important information for diagnosis and prevention. The American Society of Tropical Medicine and Hygiene Article metrics loading...[doi.org]

References

Article

  1. Watt G, Walker DH. Scrub typhus. Guerrant RL, Walker DH, Weller PF, eds. Tropical Infectious Diseases Principles, Pathogens and Practice. 2nd ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2006. Vol 1: Chapter 52.
  2. Raoult D. Scrub typhus. Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2005. Vol 2: 2309-10.
  3. Berman SJ, Kundim WD. Scrub Typhus in South Vietnam: A Study of 87 Cases. Annals Internal Med. July 1973. 79:26-30.
  4. 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. 2002 Aug. 67(2):162-5
  5. Chanta C, Chanta S. Clinical study of 20 children with scrub typhus at Chiang Rai Regional Hospital. J Med Assoc Thai. 2005 Dec. 88(12):1867-72.
  6. Sirisanthana V, Puthanakit T, Sirisanthana T. Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J. 2003 Apr. 22(4):341-5.
  7. Edwards MS, Feigen RD. Rickettsial and Erlichial Diseases. Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier Saunders; 2009. Vol 2: 2677-2678.
  8. 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. 2007 Sep. 51(9):3259-63.
  9. 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.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 20:59