The silent killer: ARDS in scrub typhus patients

Rickettsial diseases are an important cause of fever of acute onset and short duration. Transmitted by mites , rickettsial infections are an important differential when treating patients with fever exposed to such an environment. The common clinical manifestations include apart from fever, a viral rash, presence of eschar, evidence of loss of fluid in third spaces like pleural effusion and ascites. Laboratory investigations that favour rickettsial infections include presence of thrombocytopenia, leukopenia, hyponatremia, hypoalbuminemia. These findings on investigations should prompt a clinician to investigate for rickettsial infections particularly scrub typhus. Although the classical clinical picture is as described above, children can present with unusual presentation due to multiorgan failure resulting in a myriad of clinical presentations like respiratory distress, encephalitis etc. A high index of suspicion should be kept in such cases of multiorgan involvement for investigation and treatment of scrub typhus which is an easily treatable cause of multiorgan failure. METHODOLOGY: after taking informed consent from parents, we reviewed four cases of children between 7 to 10 years who presented in a tertiary care hospital with the complaint of fever of acute onset and subsequently developed acute respiratory distress syndrome (ARDS). They were subsequently diagnosed as scrub typhus and showed good response to doxycycline. CONCLUSION: scrub typhus as a cause of acute respiratory distress must be kept in mind in children presenting with acute onset fever. Although pathognomic, presence of an eschar does not predict the severity of disease. Definitive tests for scrub typhus may be negative in the initial phase of illness and must be interpreted with caution when dealing with such cases.