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Identifying eschar in acute undifferentiated febrile illness: Saving lives!


 Department of Medicine, Naval Hospital Asvini Colaba, Mumbai, Maharashtra, India

Date of Submission26-May-2020
Date of Decision26-Jun-2020
Date of Acceptance07-Aug-2020

Correspondence Address:
VA Arun,
Department of Medicine, Naval Hospital Asvini Colaba, Mumbai - 400 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_286_20

  Abstract 


Scrub typhus is one of the common causes of acute undifferentiated febrile illnesses in India. The manifestations are protean, are nonspecific, and may lead to multiorgan dysfunction syndrome and mortality if prompt recognition and treatment is not received. Identification of eschar through meticulous examination and consequent empirical use of doxycycline can save lives.

Keywords: Doxycycline, eschar, scrub typhus



How to cite this URL:
Arun V A, Nair VG, Kamble M. Identifying eschar in acute undifferentiated febrile illness: Saving lives!. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=319298



A 42-year-old male presented with a history of fever and dry cough of 5 days' duration. The fever was continuous and associated with chills, rigors, myalgia, and headache. Examination revealed an eschar on the scapha of the right earlobe though he denied any mite or tick bite during the last 1 month [Figure 1]. A diagnosis of scrub typhus was considered, and he was started on doxycycline. Investigation revealed neutrophilic leukocytosis (total leukocyte count 16,800/μl with 80% neutrophils), thrombocytopenia (42,000/μl), and raised transaminase levels (aspartate transaminase/alanine aminotransferase 123/245 U/L). On day 3 of admission, Weil–Felix test showed reactive titers of 1:40 for Proteus antigen OX 2 and 1:80 titers for Proteus antigen OX K. Immunoglobulin M antibody for Orientia tsutsugamushi by immunochromatography was positive. He was treated with 7 days of doxycycline and became afebrile in 24 h with an uneventful recovery.
Figure 1: An eschar on the scapha of the right earlobe

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Scrub typhus is an acute febrile illness endemic in the "tsutsugamushi triangle" region of the world. It is a significant public health threat in India, yet it is underrecognized and grossly underdiagnosed. Scrub typhus came into prominence during World War II along the Indo-Myanmar border in India, and numerous outbreaks have been described from all parts of the country since then.[1] Clinical features include fever, myalgia, headache, rash, and pathognomonic eschar. The disease can lead to multiorgan dysfunction in at least one-third of the cases, and the mortality of untreated disease is >50%.[2] Eschar, a 5- to 20-mm-sized necrotic lesion on the skin, is formed by the bite of chigger mite that inoculates the causative agent of scrub typhus O. tsutsugamushi. Although it can clinch the diagnosis, it often goes unnoticed as the mite bite is painless.[3] Meticulous examination of the probable sites of eschar, especially the flexures irrespective of mite bite history in all acute undifferentiated febrile illnesses, helps in documenting eschar in 50%–60% of proven scrub typhus cases [Figure 2].[4] This can result in presumptive diagnosis of scrub typhus and use of doxycycline at the first point of contact with primary care provider and save lives. This assumes importance as serological tests for scrub typhus such as Weil Felix test are not sensitive in the first 5 days of illness and tests such as enzyme-linked immunosorbent assay or polymerase chain reaction are not available in most resource-limited settings.[5]
Figure 2: Probable sites of eschar which needs to be assessed while examining a patient with acute undifferentiated febrile illness

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ranjan J, Prakash JA. Scrub typhus re-emergence in India: Contributing factors and way forward. Med Hypotheses 2018;115:61-4.  Back to cited text no. 1
    
2.
Mathai E, Rolain JM, Verghese GM, Abraham OC, Mathai D, Mathai M, et al. Outbreak of scrub typhus in southern India during the cooler months. Ann N Y Acad Sci 2003;990:359-64.  Back to cited text no. 2
    
3.
Kundavaram AP, Jonathan AJ, Nathaniel SD, Varghese GM. Eschar in scrub typhus: A valuable clue to the diagnosis. J Postgrad Med 2013;59:177-8.  Back to cited text no. 3
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4.
Kim DM, Won KJ, Park CY, Yu KD, Kim HS, Yang TY, et al. Distribution of eschars on the body of scrub typhus patients: A prospective study. Am J Trop Med Hyg 2007;76:806-9.  Back to cited text no. 4
    
5.
Isaac R, Varghese GM, Mathai E, J M, Joseph I. Scrub typhus: prevalence and diagnostic issues in rural Southern India. Clin Infect Dis 2004;39:1395-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

 
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