Neonatal Scrub Typhus with an Eyelid Eschar Masquerading as “Late-onset Sepsis”

Dinesh Kumar Narayanasamy; Thirunavukkarasu Arun Babu

doi:10.4103/ipcares.ipcares_152_22

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 4 | Page : 249-251

Neonatal Scrub Typhus with an Eyelid Eschar Masquerading as “Late-onset Sepsis”

Dinesh Kumar Narayanasamy¹, Thirunavukkarasu Arun Babu²
¹ Department of Pediatrics, JIPMER, Karaikal, Puducherry, India
² Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Mangalagiri, Andhra Pradesh, India

Date of Submission	30-Jun-2022
Date of Decision	02-Sep-2022
Date of Acceptance	29-Oct-2022
Date of Web Publication	29-Nov-2022

Correspondence Address:
Dr. Thirunavukkarasu Arun Babu
Department of Pediatrics, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipcares.ipcares_152_22

Abstract

Background: Scrub typhus is a mite-borne infection caused by the bacterium, Orientia tsutsugamushi. It is re-emerging in many parts of South East Asia, particularly in rural India. Although no age group is immune to this infection, scrub typhus in neonates is rarely suspected and reported. Here, we report a neonate with scrub typhus who was initially misdiagnosed as “late-onset neonatal sepsis.” Clinical Description: A 26-day-old exclusively breastfed infant presented with fever, vomiting, loose stools, abdominal distension, and refusal of feeds for 3 days. Examination revealed an irritable, febrile, and pale infant. She had tachycardia and facial puffiness. On abdominal examination, generalized distension with hepatosplenomegaly was noted. Blood investigations were suggestive of lymphocytic leukocytosis, thrombocytopenia, toxic granules in peripheral smear, and elevated C-reactive protein. Management: The infant was promptly started on empirical antibiotics for “late-onset sepsis.” However, in view of poor response, other possible differential diagnoses were considered. Careful reexamination revealed a necrotic ulcer covered by a yellow scab with erythematous rim on the left lower eyelid. Based on the clinical presentation and an eschar-like lesion, scrub typhus was suspected. The neonate was started on oral azithromycin and immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) testing for scrub typhus came back positive. Fever subsided immediately within 48 h and the infant was discharged after 7 days. Conclusion: Acute febrile illness due to scrub typhus can affect newborns. A high index of suspicion is required for early diagnosis. Timely treatment leads to prompt clinical response and reduced complications.

Keywords: Chigger, eschar, febrile illness, neonate, newborn

How to cite this article:
Narayanasamy DK, Babu TA. Neonatal Scrub Typhus with an Eyelid Eschar Masquerading as “Late-onset Sepsis”. Indian Pediatr Case Rep 2022;2:249-51

How to cite this URL:
Narayanasamy DK, Babu TA. Neonatal Scrub Typhus with an Eyelid Eschar Masquerading as “Late-onset Sepsis”. Indian Pediatr Case Rep [serial online] 2022 [cited 2023 Sep 26];2:249-51. Available from: http://www.ipcares.org/text.asp?2022/2/4/249/362235

Scrub typhus is a re-emerging, tropical zoonosis, transmitted by chiggers, the larval stages of trombiculid mites belonging to Leptotrombidium species. The causative organism, Orientia tsutsugamushi, enters the host through a chigger bite which later evolves into an eschar, a necrotic lesion in the skin at the site of chigger bite.^[1] Children of all age groups are at risk of developing this infection, but neonatal cases of scrub typhus are rarely reported.^[2],[3]

A high index of suspicion is needed in young infants. Delayed diagnosis can be complicated by end-organ failure and increased mortality.^[2] When diagnosed early and treated on time, scrub typhus responds well to antimicrobials, such as azithromycin or doxycycline.^[4] We report a case of neonatal scrub typhus which is relatively rare and was misdiagnosed as “late-onset sepsis” due to its nonspecific clinical presentation.

Clinical Description

A 26-day-old girl was brought to the casualty with complaints of fever for 3 days, vomiting with loose stools for 2 days along with abdominal distension, and refusal to feed for 1 day. The neonate initially developed vomiting, which was acute in onset, 6–8 times/day, mostly after feeds, nonbilious, and nonprojectile. Loose stools were 10–12 episodes/day, yellow, not associated with blood or mucus, and associated with abdominal distension. The urine output was decreased, but not associated with crying after micturition, dribbling of urine or any blood, or pus noted per urethra. The refusal of feeds was associated with lethargy. The baby was exclusively breastfeed and there was no history of progressive paleness, yellowish discoloration of eyes or body, any skin lesion, or any harmful child-rearing practices such as bottle feeding, top milk feeds, ghutti or water intake, or oil instillation in the nose/mouth.

She was the first issue of nonconsanguineous parents, delivered at term gestation by normal delivery following an uneventful antenatal period. She cried immediately at birth and her birth weight was 3.2 kg. There were no significant perinatal events and she was discharged on the 3^rd day of life.

At admission, she was febrile (axillary temperature 39°C) and had a pulse rate of 166/min with normal perfusion (blood pressure of 86/60 mm of Hg). Her respiratory rate was 46 breaths/min and saturation at room air was 96% on the right hand. Her anthropometric measures were within the normal range as per the WHO percentile chart for girls, with a weight of 3.8 Kg (50^th–15^th percentile), length of 52 cm (50^th percentile), and head circumference of 36.5 cm (50^th percentile). On examination, she was irritable and pale with bilateral periorbital puffiness but no eye discharge. There were no associated findings such as jaundice, maculopapular skin rashes, and dependent edema at any other site or sclerema.

Abdominal examination revealed nontender and diffuse abdominal distension with hepatosplenomegaly (liver 2.5 cm below the right costal margin, with a span of 7 cm, and spleen 3 cm below the left costal margin, in the axis of the 10^th rib). Bowel sounds were normal. The anterior fontanelle, cry, activity, spontaneous movements, tone, and neonatal reflexes were within normal limits. Examination of the cardiovascular and respiratory systems was noncontributory. Based on the clinical presentation, late-onset sepsis with the possibility of meningitis, gastroenteritis, or urinary tract infection was suspected.

Management and outcome

The neonate was treated with supportive therapy and injectable antibiotics (cefotaxime and amikacin). The preliminary hemogram revealed anemia (hemoglobin –10.4 gm%), leukocytosis (total leukocyte count –14,700 cells/mm³), normal differential leukocyte count (35% polymorphs, 61% lymphocytes, and 4% eosinophils), and thrombocytopenia (platelet count –98000 cells/mm³). The C-reactive protein was 60 mg/dL (normal <6 mg/dL) and micro erythrocyte sedimentation rate (micro-ESR) (1 h) 30 mm. The peripheral smear showed toxic granules. Results of other laboratory tests such as blood sugar, electrolytes, liver function, and kidney function tests were within normal limits. Lumbar puncture was not done due to low platelet count. The urine routine and microscopy examination were within normal limits.

Supine abdominal X-ray did not reveal any dilated bowel loops, bowel wall edema, or features suggestive of pneumatosis intestinalis. The ultrasound of the abdomen showed free fluid with hepatosplenomegaly. Cranial ultrasound and echocardiography were normal. Rapid malarial test and dengue serology were negative. The blood and urine cultures were sterile.

In spite of 48 h of therapy, the fever and refusal of feeds persisted. On re-examination, we noted a shallow ulcer covered by a yellow scab with erythematous rim on the left lower eyelid [Figure 1]. This had not been evident at admission due to the puffy eyelids. This led us to suspect scrub typhus. On probing, we elicited the history of the mother placing the baby on bare ground without using a sheet while she cooked outside the house. She also had a habit of drying the washed clothes on the surrounding scrub vegetation, instead of using a clothesline.

Figure 1: Atypical eschar on the left lower eyelid (black arrow)

Click here to view

The neonate was started on oral azithromycin after sending immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) for scrub typhus. The fever reduced and the baby started breastfeeding well within 48 h. The IgM ELISA for scrub typhus was positive with an optical density (OD) value of 1.92 (normal is <0.5 OD). Within the next 2 days, the eyelid edema subsided, hepatosplenomegaly regressed, and the platelet count normalized. She was discharged after 7 days of therapy.

Discussion

Scrub typhus is a re-emerging infection causing acute febrile illness in children. The initial presentation is nonspecific and mimics other common tropical infections such as sepsis, dengue fever, malaria, enteric fever, and pneumonia, particularly in younger children.^[4]

Most neonatal scrub typhus presents with features of “late-onset sepsis,” whereas severe cases may even present with shock and respiratory failure.^[3] The diagnosis is often missed as the eschar, which is a pathognomic sign of scrub typhus, is less commonly seen in neonates.^[5] The eschars are commonly seen in the anatomical folds of the groin and axilla. Its occurrence on the face is uncommon and involvement of the eyelid is rare.^[5],[6] A case of eyelid eschar has been reported in a 5-year-old child who presented with fever and eyelid swelling.^[6]

IgM ELISA is a commonly used serological test for confirming the diagnosis. This becomes positive only after 5–7 days of the onset of fever. Thus, a high index of suspicion in the 1^st week of infection should be based on clinicolaboratory findings.^[7] Doxycycline is preferred over azithromycin in the treatment of scrub typhus due to its swift response without any adverse effects.^[8],[9] Defervescence usually occurs within 48 h (as seen in this case), although delayed fever clearance can be expected in severe cases with organ dysfunction.^[10],[11]

Apart from rodent control, prevention of exposure to chiggers can prevent the acquisition of scrub typhus, especially in rural areas.^[12] Outdoor cooking has been considered a modifiable behavioral risk factor for acquiring scrub typhus. This provides a favorable environment for both chiggers and rodents.^[12] Similarly, drying washed clothes on scrub vegetation, a common practice in rural India, has been found to increase child-chigger contact. The use of a clothesline would be an effective protective measure.^[12] To conclude, scrub typhus should be considered a differential diagnosis in any neonate presenting with features of sepsis, particularly in endemic areas. History regarding behavioral risk factors for acquiring scrub typhus along with the search for eschar should be elicited in all suspected cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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