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LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 1074-1075

Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation


Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission16-Sep-2019
Date of Decision10-Jul-2020
Date of Acceptance17-Sep-2020
Date of Web Publication2-Sep-2021

Correspondence Address:
Ahmad Ozair
Faculty of Medicine, King Georgefs Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.325368

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How to cite this article:
Abbas SF, Ozair A, Kumar V, Himanshu D. Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation. Neurol India 2021;69:1074-5

How to cite this URL:
Abbas SF, Ozair A, Kumar V, Himanshu D. Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation. Neurol India [serial online] 2021 [cited 2021 Sep 25];69:1074-5. Available from: https://www.neurologyindia.com/text.asp?2021/69/4/1074/325368




Sir,

We here present a case of scrub typhus (ST) manifesting with hemiparesis, which, to the best of our knowledge, has been reported few times prior.[1] ST typically presents with headache, fever, cough, dyspnoea, and/or gastrointestinal symptoms.[2],[3] Early treatment ensures swift improvement. However, this common cause of febrile illness is often overlooked, even in endemic regions. This is due to a nonspecific presentation, low index of suspicion, and lack of diagnostic facilities.[2],[4] Even our institution, an apex public referral center of northern India, lacked affordable testing a decade ago. After testing began, a significant number of cases, which would have previously been labeled as “fever of unknown origin,” were found to be of ST and confirmed by response to doxycycline.

A 75-year-old male presented with acute-onset altered sensorium and left-sided hemiparesis, with a week's history of fever, productive cough, and breathlessness. While hemodynamically stable, he had bilateral crepitations with Glasgow Coma Scale of E4V3M4. There were bilateral flexor plantar responses, normal reflexes, absent neck rigidity, and no other neurological deficits. Other systems were unremarkable.

Initial investigations revealed leukocytosis, thrombocytopenia, stage-1 acute kidney injury, raised serum transaminases, and alkaline phosphatase. No derangements were present in serum electrolytes, bilirubin, albumin, and glucose. Cerebrospinal fluid (CSF) had protein 110 mg/dL, normal glucose (corresponding to plasma glucose), leucocyte count 30/mm3 with pleocytosis, and adenosine deaminase (ADA) 14.2 IU/L, raising suspicion of tubercular meningitis. CSF serology for dengue, Japanese encephalitis, Chikungunya, Herpes-Simplex virus, and India-Ink staining were all negative.

While conservative in-patient management continued, brain MRI revealed meningoencephalitis and diffusion restriction [Figure 1]. Anti-ST IgM antibodies by ELISA were positive, endorsing a diagnosis of ST as per Indian Council of Medical Research guidelines.[4] Doxycycline administration resulted in rapid improvement.
Figure 1: (a-c) Restricted diffusion on the right-sided temporo-parieto-occipital cortex on diffusion-weighted imaging, suggestive of encephalitis (arrows). (d and e) Leptomeningeal enhancement on an axial section of contrast-enhanced brain MRI, suggestive of meningitis (arrows)

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The patient was discharged within a week, with normal renal and hepatic function. Follow-up revealed complete resolution without functional deficits.

This is one of the rare reported cases in literature of ST presenting with hemiparesis, which was secondary to either stroke.[1] We have also seen ST paradoxically present as isolated lateral rectus palsy and intracerebral hemorrhage.[5],[6] Because ST can manifest with multiorgan dysfunction and/or death in cases of therapeutic delay, early diagnosis is critical.[2],[3]

ST-induced meningitis or meningoencephalitis is reported in 14–83% of cases, with differential diagnoses being tubercular meningitis and cerebral malaria.[3] CSF analysis, especially ADA levels and anti-ST IgM testing, is crucial in a nation where above etiologies are endemic.[1],[4]

To conclude, serological testing for ST urgently needs to be made widely available pan-India.[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chen PH, Hung KH, Cheng SJ, Hsu KN. Scrub typhus-associated acute disseminated encephalomyelitis. Acta Neurol Taiwan 2006;15:251-4.  Back to cited text no. 1
    
2.
Mahajan SK. Scrub typhus. J Assoc Physicians India 2005;53:953-8.  Back to cited text no. 2
    
3.
Mahajan SK, Mahajan SK. Neuropsychiatric manifestations of scrub typhus. J Neurosci Rural Pract 2017;8:421-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Rahi M, Gupte MD, Bhargava A, Varghese GM, Arora R. DHR-ICMR Guidelines for diagnosis and management of rickettsial diseases in India. Indian J Med Res 2015;141:417-22.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Ozair A, Kumar V, Himanshu D, Bhat V. A rare etiology behind isolated lateral rectus palsy: Scrub typhus. J Family Med Prim Care 2020;9:2538-40.  Back to cited text no. 5
  [Full text]  
6.
Kotwal M, Vaish E, Gupta KK, Ozair A. Scrub typhus manifesting with intracerebral hemorrhage: Case report and review of literature. J Family Med Prim Care 2020;9:2535-7.  Back to cited text no. 6
  [Full text]  


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