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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 130-132

Splenic abscess: A rare complication of scrub typhus in a child


1 Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiodiagnosis, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission25-Feb-2021
Date of Decision03-May-2021
Date of Acceptance06-May-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Lesa Dawman
Department of Pediatrics, Advanced Pediatrics Centre, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_58_21

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  Abstract 

Background: Scrub typhus is endemic in the various parts of the world and especially in the Indian subcontinent. Splenic infarcts and abscess are largely unknown in scrub typhus. These can be a source of persistent abdominal pain in the left hypochondriac region. Clinical Description: A 9-year-old child presented with a 7-day history of fever, loose stools, respiratory distress, and abdominal pain. On examination, she was febrile, had tachypnea, tachycardia, pallor, and facial puffiness. Systemic examination showed pleural effusion and hepatomegaly. Acute febrile illness with third spacing led to differentials of tropical infections (dengue, scrub typhus, enteric fever, and malaria). Management: Dengue, enteric fever, and malaria were ruled out on investigations. Scrub IgM enzyme-linked immunosorbent assay was positive. Ultrasound of the abdomen showed multiple splenic anechoic lesions suggestive of abscesses. Contrast-enhanced computed tomography (CT) confirmed the findings. Ultrasonography-guided aspiration of the lesion revealed blood-stained pus. The gram stain was negative, and culture was sterile. The final diagnosis was scrub typhus with splenic abscess. Her symptoms resolved with doxycycline therapy. Conclusion: Involvement of the spleen resulting in infarct and abscess is a rare complication in scrub typhus and can lead to persisting abdominal symptoms. Splenic infarction is not a well-known complication in patients of scrub typhus; hence, it may lead to under diagnosis of the condition. An abdominal ultrasound or if required, CT scan of the abdomen might be needed in cases with persistent abdominal symptoms to rule out this rare complication.

Keywords: Abscess, child, scrub typhus, splenic infarct


How to cite this article:
Sharma R, Marodia Y, Dawman L, Bhatia A, Tiewsoh K. Splenic abscess: A rare complication of scrub typhus in a child. Indian Pediatr Case Rep 2021;1:130-2

How to cite this URL:
Sharma R, Marodia Y, Dawman L, Bhatia A, Tiewsoh K. Splenic abscess: A rare complication of scrub typhus in a child. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Jun 19];1:130-2. Available from: http://www.ipcares.org/text.asp?2021/1/2/130/317359

Scrub typhus is caused by a bite of trombiculid mite, and the causative agent is orientia tsutsugamushi. The disease in endemic in the Indian subcontinent and is prevalent in the months of June through November. If left untreated, the mortality rate of scrub typhus is about 30%.[1] The typical manifestation is multiorgan dysfunction secondary to endothelial damage. Involvement of the abdomen, liver, central nervous system, and respiratory system is well-known. The common abdominal imaging findings include hepatomegaly, splenomegaly, gall bladder wall thickening, and lymphadenopathy.[2] Splenic infarcts have been reported infrequently. These usually manifest as diffuse or left hypochondriac abdominal pain and are likely secondary to either direct invasion of the organisms or immune mediated vasculitis seen in scrub typhus and may get complicated by abscess formation. To the best of our knowledge, this is the first case report of scrub typhus with splenic abscess, which is one of the rare complications of scrub typhus.

We report a case of scrub typhus in a child who presented with multi-organ involvement that resolved but was followed by persistent left hypochondriac pain. She was evaluated for the abdominal pain, and on abdominal ultrasonography (USG), multiple splenic infarcts with likely abscess formation of different sizes were detected.


  Clinical Description Top


A 9-year-old girl presented with a history of high grade fever for 7 days, loose stools for 5 days, and increased respiratory rates for 3 days. She also had abdominal pain, which was dull aching and diffuse for 3 days with no aggravating or relieving factors. There was no history of cough, rash, vomiting, or decreased urine output. She was treated at a nearby local hospital conservatively with intravenous (IV) fluids for 3 days and was referred to our center when the respiratory distress worsened.

Vitals revealed fever (103°F), tachypnea, tachycardia, and normal blood pressure. In view of tachypnea with oxygen saturation in room air at 95%–96%, she was started on nasal prong oxygen. She had pallor, facial puffiness, pedal edema, and ascites. There was no lymphadenopathy, icterus, rashes, petechiae, or joint involvement. No eschar was found. Respiratory system examination showed dullness on bilateral inframammary and infra-axillary regions with decreased air entry suggestive of bilateral pleural effusion. On abdominal examination, she had hepatomegaly (3 cm below right costal margin in the mid-clavicular line) and no splenomegaly. The rest of the systemic examination was normal. Considering the clinical phenotype of an acute febrile illness with hepatomegaly and features of third spacing, the differential diagnoses of common tropical infections (enteric fever, scrub typhus, dengue, and malaria) were kept, and investigations planned accordingly.

Management and Outcome

Dengue fever was kept as the first differential diagnosis; however, the rapid test for IgM and NS-1 antigen was negative. The child had microcytic hypochromic anemia (Hb: 10.3 g/dL; no hemoconcentration) with thrombocytopenia (platelet count 34,000/mm3) and leukocytosis (total leukocyte count 11400/mm3; differential leukocyte counts P51, L43, M5, E1). Serum electrolytes (sodium: 140 mEq/L, potassium: 4.1 mEq/L, and chloride: 95 mEq/L) and transaminases (aspartate aminotransferase: 28 mg/dL, alanine aminotransferase: 17 mg/dL) were normal. Renal function test at admission was 17 mg/dL and serum creatinine 0.24 mg/dL. Enteric fever was excluded by sterile blood culture and negative Widal test. Malarial parasite smear was negative. IgM enzyme-linked immunosorbent assay for scrub typhus was positive (optical density >4). Scrub typhus polymerase chain reaction kit was not available at the time in our center.

At the time of admission, she was started on IV ceftriaxone and doxycycline along with other supportive measures. She became afebrile after 48 h of starting doxycycline, pleural effusion resolved, and she was made off oxygen support by day 6 of hospital stay. However, on day 7 of hospital stay, the child had abdominal pain predominantly in the left hypochondriac region. Physical examination was inconclusive. Ultrasound of the abdomen showed multiple well-defined anechoic lesions with internal echoes within, suggestive of abscesses in the spleen [Figure 1]a and [Figure 1]b. Contrast-enhanced computed tomography (CT) image showed splenomegaly with peripheral wedge shaped as well as lobulated nonenhancing hypodense lesions of varying sizes within the splenic parenchyma [Figure 2]. USG-guided aspiration of the lesions revealed blood-stained pus. The gram stain was negative, and culture was sterile. Doxycycline was given for 7 days and ceftriaxone for 14 days. At the time of discharge, the platelet count was 204,000/mm3. The final diagnosis was scrub typhus with splenic infarcts and splenic abscess. At the time of discharge, she was symptom-free.
Figure 1: (a and b) Ultrasound of the abdomen showing multiple well-defined anechoic lesions with internal echoes within suggestive of abscesses

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Figure 2: Contrast-enhanced computed tomography image of the abdomen shows splenomegaly with peripheral wedge shaped as well as lobulated nonenhancing hypodense lesions of varying sizes within the splenic parenchyma

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  Discussion Top


Scrub typhus is one of the most common tropical infections in children and adults and one million new cases occur each year. It is estimated that 1 billion are at risk of contracting the infection.[3] The incubation period of scrub typhus is 10–12 days (range: 6–21 days). The symptoms most commonly include fever and rash with or without the characteristic eschar. Scrub typhus manifests with multiorgan involvement in some cases with myriad of symptoms. The complications of scrub typhus can be seen in almost all major organ systems and the associated findings, not limited to those mentioned, include: cardiovascular, respiratory, neurologic, gastrointestinal, renal injury, and complications such as hemophagocytic lymphohystiocytosis.[4]

Splenic abscesses are rare complication, and the exact incidence or prevalence is unknown. The autopsy reports of all age groups found prevalence to be around 0.05%–0.7%.[5] Splenic abscesses are usually seen with infective endocarditis, acquired immunodeficiency syndrome, diabetes mellitus, immune deficiencies, and others. The formation of splenic abscess in these conditions can be explained by septic embolization, splenic infarcts (secondary to vasculitis) as the starting point for abscess, and contagious spread from surrounding organs. Abscess development in a splenic infarct secondary to the generalized vasculitic processes seen in scrub typhus seems plausible. If left untreated, splenic abscess can lead to severe morbidity and mortality.[5] It is difficult to comment on the exact prognosis of splenic infarcts/abscess in scrub typhus as many cases probably go undetected. Abscess formation may lead to persistence of symptoms or occurrence of new symptoms. Antibiotics may be required for longer duration in the presence of abscess and the abscess may require drainage in some cases for symptom and source control. Ultrasound and computerized tomography scans are both sensitive modalities for the diagnosis of splenic infarcts and abscess, although both have a slightly lower specificity. The presence of liquid material inside the cavity characterizes necrosis or abscess formation. In this case, since the radiologist was unable to unequivocally characterize the lesions on USG, as they were multiple, we had to proceed with a CT scan.

Splenic infarcts have been mentioned as a presenting feature[6] or as a complication[7] of scrub typhus in isolated case reports.[2],[6],[7],[8],[9],[10],[11],[12] A case report from South India of a 4-year-old girl who presented with acute febrile illness and encephalopathy showed the presence of eschar and splenomegaly.[12] USG abdomen showed fluid in the peritoneal cavity and multiple splenic infarcts which were confirmed on CT scan. The child was treated with anti-raised intracranial pressure measures, ceftriaxone, and doxycycline. She showed improvement in sensorium from day 4. The splenomegaly regressed and repeat USG abdomen was normal. A similar case from North India was reported in an 8-year-old boy who presented with acute febrile illness and had tachycardia and tachypnea at presentation. On examination, he had eschar on his inner thigh. He complained of persistent left hypochondriac pain and abdominal CT revealed splenic infarction. He was treated with doxycycline and his symptoms resolved.[11] A retrospective study by Park et al.[2] evaluated abdominal imaging findings in scrub typhus in 94 Korean patients presenting with abdominal complaints over 5 years (2008–2013). The findings in the descending order of frequency were as follows: enlarged lymph nodes (53.2%), hepatomegaly (47.9%), splenomegaly (46.8%), and ascites (28.7%). The prevalence of splenic infarction was only 6.4%. A similar study by Kim et al.[8] in 78 Korean patients revealed splenic infarcts in 3.8% patients. Both these studies were planned based on the imaging profile rather than the clinical profile, and neither included children. Thus, splenic infarcts and abscesses are rare complications in scrub typhus and can lead to persisting abdominal symptoms, particularly localized to the hypogastrium region. Abdominal imaging may be needed in these cases.



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Rajapakse S, Rodrigo C, Fernando D. Scrub typhus: Pathophysiology, clinical manifestations and prognosis. Asian Pac J Trop Med 2012;5:261-4.  Back to cited text no. 1
    
2.
Park MJ, Lee HS, Shim SG, et al. Scrub typhus associated hepatic dysfunction and abdominal CT findings. Pak J Med Sci 2015;31:295-9.  Back to cited text no. 2
    
3.
Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis 2003;16:429-36.  Back to cited text no. 3
    
4.
Rajapakse S, Weeratunga P, Sivayoganathan S, et al. Clinical manifestations of scrub typhus. Trans R Soc Trop Med Hyg 2017;111:43-54.  Back to cited text no. 4
    
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Datey SM, Charles N, Patidar H, et al. Splenic abscess: Review Article. J Evol Med Dent Sci 2015;4:5569-76.  Back to cited text no. 5
    
6.
Goyal MK, Porwal YC, Gogna A, et al. Splenic infarct with scrub typhus: A rare presentation. Trop Doct 2020;50:234-6.  Back to cited text no. 6
    
7.
Durey A, Kwon HY, Park YK, et al. A Case of Scrub Typhus complicated with a Splenic Infarction. Infect Chemother 2018;50:55-8.  Back to cited text no. 7
    
8.
Kim KY, Song JS, Park EH, et al. Scrub typhus: radiological and clinical findings in abdominopelvic involvement. Jpn J Radiol 2017;35:101-8.  Back to cited text no. 8
    
9.
Hwang JH, Lee CS. Incidentally Discovered Splenic Infarction Associated with Scrub Typhus. Am J Trop Med Hyg 2015;93:435.  Back to cited text no. 9
    
10.
Raj SS, Krishnamoorthy A, Jagannati M, et al. Splenic infarct due to scrub typhus. J Glob Infect Dis 2014;6:86-8.  Back to cited text no. 10
    
11.
Kapoor S, Upreti R, Mahajan M. Splenic infarct secondary to scrub typhus: A rare association. J Vector Borne Dis 2019;56:383-4.  Back to cited text no. 11
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12.
Rajkumar A. Case report of Scrub typhus with splenic infarct as a complication. University J Med Med Special 2018;4:2455-852.  Back to cited text no. 12
    


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