American Journal of Medical Case Reports
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American Journal of Medical Case Reports. 2017, 5(3), 69-76
DOI: 10.12691/ajmcr-5-3-7
Open AccessArticle

A Probable Case of Scrub Typhus Meningoencephalitis – In the Era of Dual Seropositivity and Possible Emerging Doxycycline Resistance - Are Dictums Changing?

Soumyabrata Roy Chaudhuri1, , Deep Das2, Hindol Dasgupta3, Dipnarayan Mukherjee4 and Kingshuk Bhattachacharjee5

1Consultant Diabetologist, Woodlands Hospital, 8/5, Alipore Road, Alipore, Kolkata, West Bengal, India

2Consultant Neurologist, Woodlands Hospital, 8/5, Alipore Road, Alipore, Kolkata, WestBengal, India

3Consultant Pulmonologist, Woodlands Hospital -1, 8/5, Alipore Road, Alipore, Kolkata, West Bengal, India

4Consultant Microbiologist, Woodlands Hospital-1, 8/5, Alipore Road, Alipore, Kolkata, WestBengal, India

5Independent Medical Writer & Biostatistician, Kolkata

Pub. Date: April 13, 2017

Cite this paper:
Soumyabrata Roy Chaudhuri, Deep Das, Hindol Dasgupta, Dipnarayan Mukherjee and Kingshuk Bhattachacharjee. A Probable Case of Scrub Typhus Meningoencephalitis – In the Era of Dual Seropositivity and Possible Emerging Doxycycline Resistance - Are Dictums Changing?. American Journal of Medical Case Reports. 2017; 5(3):69-76. doi: 10.12691/ajmcr-5-3-7

Abstract

Scrub typhus is an acute febrile illness which has varied manifestation from febrile illness to a more severe multi-organ dysfunction including CNS involvement in the form of meningitis and meningoencephalitis and in extremes cases, septic shock and death. Scrub typhus is prevalent in India and there have been reported case series from north-eastern regions of India and also from various institutes of south India. In sharp contrast, our case is a single incidence and classically showed features of lung involvement which predisposes to CNS involvement (in the form of meningitis or meningoencephalitis) later. All the published case reports/series from the subcontinent, it is unanimously stated that response is dramatic upon starting of oral doxycycline and the clinical scenario changes within 48- 72 hours. However in this anecdotal case of ours, intravenous doxycycline was started and still patient went downhill before he stabilised after 10 days of the therapy. Although doxycycline failures have been reported from Korea and the medical scientists have put forward their explanations about the questionable emerging resistance to doxycycline, still this case remains important because it is one of the first reported cases from the Indian subcontinent where the clinical features deteriorated even after starting Doxycycline ("The erstwhile gold standard antibiotic against Scrub Typhus) and that too via intravenous route. The case presents a dilemma in the minds of the clinician as to what strategy may be taken to achieve higher MIC values of Doxycycline (to overcome the emerging resistance) and also triggers the search for new antibiotic regimen which can help us to control scrub typhus early and prevent the more severe and life threatening complications of the disease.

Keywords:
scrub typhus meningoencephalitis doxycycline resistance dual seropositivity India

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References:

[1]  Kim SJ, Chung IK, Chung IS, Song DH, Park SH, Kim HS, LeeMH, 2000. The clinical significance of upper gastrointestinalendoscopy in gastrointestinal vasculitis related to scrub typhus. Endoscopy 32: 950-955.
 
[2]  Ogawa M, Hagiwara T, Kishimoto T, Shiga S, Yoshida Y, FuruyaY, Kaiho I, Ito T, Nemoto H, Yamamoto N, Masukawa K,2002. Scrub typhus in Japan: epidemiology and clinical features of cases reported in 1998. Am J Trop MedHyg 67:162-165.
 
[3]  Thap LC, Supanaranond W, Treeprasertsuk S, Kitvatanachai S, Chinprasatsak S, Phonrat B, 2002. Septic shock secondary to scrub typhus: characteristics and complications. Southeast Asian J Trop Med Public Health 33: 780-786.
 
[4]  Scrub typhus meningoencephalitis, a diagnostic challenge for clinicians: A hospital based study from North-East India M. D. Jamil, Masaraf Hussain, Monaliza Lyngdoh, Shriram Sharma, Bhupen Barman, and P. K. Bhattacharyadoi: 10.4103/0976-3147. 169769.
 
[5]  Liu YX, Feng D, Suo JJ, Xing YB, Liu G, et al. (2009). Clinical characteristics of the autumn-winter type scrub typhus cases in south of Shandong province, northern China. BMC Infect Dis 9: 82
 
[6]  Rajapakse S, Rodrigo C, Fernando D (2012) Scrub typhus: pathophysiology, clinical manifestations and prognosis. Asian Pac J Trop Med 5: 261-264.
 
[7]  Chattopadhyay S, Richards AL. Scrub typhus vaccines: Past history and recent developments. Hum Vaccin. 2007; 3: 73-80.
 
[8]  Liu YX, Feng D, Suo JJ, Xing YB, Liu G, Liu LH, et al. Clinical characteristics of the autumn-winter type scrub typhus cases in South of Shandong province, northern China. BMC Infect Dis. 2009; 9: 82.
 
[9]  Thakur JS, Mohindroo NK, Sharma DR, Soni K, Kaushal SS (2011) Evoked response audiometry in scrub typhus: prospective, randomised, case-control study. J Laryngol Otol 125: 567-571.
 
[10]  Lai CH, Chen YH, Lin JN, Chang LL, Chen WF, et al. (2009) Acute Q fever and scrub typhus, southern Taiwan. Emerg Infect Dis 15: 1659-1661.
 
[11]  Harden VA (1993) Typhus, Scrub (Tsutsugamushi). In: The Cambridge World History of Human Disease Kiple KF, editor. Cambridge University Press. 153: 355-356.
 
[12]  Parola P, Raoult D (2006) Tropical rickettsioses. Clin Dermatol 24: 191-200.
 
[13]  Oaks JSC, Ridgway RL, Shirai A, Twartz JC (1983) Scrub typhus. Bulletin No 21 United States Army Medical Research Unit, Institute for Medical Research, Malaysia 1-107.
 
[14]  Jim WT, Chiu NC, Chan WT, Ho CS, Chang JH, et al. (2009). Clinical manifestations, laboratory findings and complications of pediatric scrub typhus in eastern Taiwan. Pediatr Neonatol 50: 96-101.
 
[15]  Kim DM, Kim SW, Choi SH, Yun NR (2010). Clinical and laboratory findings associated with severe scrub typhus. BMC Infect Dis 10: 108.
 
[16]  Saifudheen K, Kumar KG, Jose J, Veena V, Gafoor VA (2012). First case of scrub typhus with meningoencephalitis from Kerala: An emerging infectious threat. Ann Indian Acad Neurol 15: 141-144.
 
[17]  Chogle AR. Diagnosis and treatment of scrub typhus--the Indian scenario.J Assoc Physicians India. 2010; 58: 11-22.
 
[18]  Scrub Typhus Meningitis in South India – A Retrospective Study. Stalin Viswanathan, Vivekanadan Muthu, Nayyar Iqbal, Bhavith Remalayam, Tarun George, Published: June 14, 2013.
 
[19]  Sittiwangkul R, Pongprot Y, Silviliarat S, Oberdorfer P, Jittamala P, et al. (2008). Acute fulminant myocarditis in scrub typhus. Ann Trop Paediatr 28: 149-154.
 
[20]  Seong SY, Choi MS, Kim IS (2001). Orientia tsutsugamushi infection: overview and immune responses. Microbes Infect 3: 11-21.
 
[21]  Mahajan SK, Rolain JM, Kanga A, Raoult D (2010). Scrub typhus involving central nervous system, India, 2004–2006. Emerg Infect Dis 16: 1641-1643.
 
[22]  Saifudheen K, Kumar KG, Jose J, Veena V, Gafoor VA (2012) First case of scrub typhus with meningoencephalitis from Kerala: An emerging infectious threat. Ann Indian Acad Neurol 15: 141-144.
 
[23]  Ko AI, Galvao Reis M, Ribeiro Dourado CM, Johnson WD Jr, Riley LW, 1999. Urban epidemic of severe leptospirosis in Brazil. Salvador Leptospirosis Study Group. Lancet 354: 820-825.
 
[24]  Pai H, Sohn S, Seong Y, Kee S, Chang WH, Choe KW, 1997. Central nervous system involvement in patients with scrub typhus. Clin Infect Dis 24: 436-440.
 
[25]  Jeong YJ, Kim S, Wook YD, Lee JW, Kim KI, et al. (2007). Scrub typhus: clinical, pathologic, and imaging findings. Radiographics 27: 161-172.
 
[26]  Lee KL, Lee JK, Yim YM, Lim OK, Bae KH (2008). Acute transverse myelitis associated with scrub typhus: case report and a review of literatures. Diagn Microbiol Infect Dis 60: 237-239.
 
[27]  Vivekanandan M, Mani A, Priya YS, Singh AP, Jayakumar S, et al. (2010). Outbreak of scrub typhus in Pondicherry. J Assoc Physicians India 58: 24-28.
 
[28]  Lin WR, Chen TC, Lin CY, Lu PL, Chen YH (2011). Bilateral simultaneous facial palsy following scrub typhus meningitis: a case report and literature review. Kaohsiung J Med Sci 27: 573-576.
 
[29]  Scrub Typhus and Leptospirosis : The fallacy of Diagnosing with IgM enzyme Linkd Immunosorbant Assay.Nitin Gupta, Rama Chaudhury, Bijay Mirdha, Bimal Das, Lalit Dar, Sushil Kabra, Rakesh Lodha, Aparjita Dey, Rita Sood, Naveet Wig, and Vishnubhatla Sreenivas, J Micro Biochem Technol 2016, 8. 2.
 
[30]  Scrub Typhus Meningitis or Meningoencephalitis Dong-Min Kim, Jong-Hoon Chung, Na-Ra Yun, Seok Won Kim, Jun-Young Lee, Mi Ah Han, and Yong-Bok LeeAm. J. Trop. Med. Hyg., 89(6), 2013, pp. 1206-1211.
 
[31]  Dotevall L, Hagberg L, 1989. Penetration of doxycycline into cerebrospinal fluid in patients treated for suspected Lyme neuroborreliosis. Antimicrob Agents Chemother 33: 1078-1080.
 
[32]  Raoult D, Drancourt M, 1991. Antimicrobial therapy of rickettsial diseases. Antimicrob Agents Chemother 35: 2457-2462.
 
[33]  Yim CW, Flynn NM, Fitzgerald FT, 1985. Penetration of oral doxycycline into the cerebrospinal fluid of patients with latent or neurosyphilis. Antimicrob Agents Chemother 28: 347-348.
 
[34]  Elsom KA, Beebe GW, Sayen JJ, Scheie HG, Gammon GD, Wood FC, 1961. Scrub typhus: a follow-up study. Ann Intern Med 55: 784-795.
 
[35]  Gupta N, Chaudhry R, Mirdha B, Das B, Dar L, et al. (2016) Scrub Typhus and Leptospirosis: The fallacy of Diagnosing with IgM Enzyme Linked Immunosorbant Assay. J Microb Biochem Technol 8: 071-075.