Things not to miss - Rickettsial infections



A 55 years old man from Hatharaliyadda (A small town which forms the margin between districts of Kurunegala, Kandy, and Kegalle) presented with a history of fever for 4 days duration. He had a headache, myalgia, arthralgia, and a faint generalized erythematous rash. There was no contact history of fever. He was a farmer who consumed alcohol regularly. On examination he looked ill, pulse rate was 100/min, blood pressure 90/60mmHg, lungs were clear and there was mild epigastric tenderness.
What are the possibilities?
  • The first differential diagnosis for this presentation is invariably dengue.
An in-ward ultrasound scan was done to look for evidence of leaking.

Image result for ultrasound hepatorenal pouch
Leaking or not??
Urgent PCV was done - it was 42%.
As there was no evidence of leaking, the patient was managed as dehydration. One pint of normal saline was given for resuscitation and 100cc/hr drip was continued for maintenance as the patient was reluctant to take fluids orally. A blue chart was maintained.

In a few hours reports were available.

WBC - 5.2 (N - 55%, L - 40%)
Hb - 12.2
Plt - 130

AST - 55
ALT - 48

S. Cr - 0.9

The same management plan was continued. However, patients' blood pressure remained on the lower side and the fever spikes continued. The rash was becoming more and more prominent.

Subsequently, patients blood pressure started to drop further, but there was no evidence of leaking. He started to desaturate and was intubated and sent to ICU.

What is this rash?






























Diagnosis?
  • Typhus fever with Fern Leaf Skin Necrosis!


What do you know about typhus (Rickettsial infections)?
  • It's a disease that has emerged and now have spread to most parts of the country.
  • However, there are several areas where it is frequently seen.
  • HATHARALIYADDA is one such area! That's exactly why you should learn a bit of epidemiology and ask all patients 'Where do you live'!
  • There are many articles on typhus by eminent clinicians of Sri Lanka, maybe it's time to read a few.
https://onlinelibrary.wiley.com/doi/full/10.1046/j.1365-3156.2003.01108.x?sid=nlm%3Apubmed
https://www.sciencedirect.com/science/article/pii/S1201971213002105



What is the usual presentation?
  • They share common clinical features with dengue including myalgia, arthralgia and headache.
  • Eschar is seen rarely.
    • Look specially in the groin area.
  • Usually ALT is more than AST, however like in this patient other factors like alcohol can alter the ratio.
  • It can cause all organ failures.
Diagnosis?
  • Mostly its clinical.
  • Serological investigations are not widely available.
How do you treat Rickettsial infections, is there a guideline?
  • Management protocols differ from unit to unit. Most clinicians use their own experience in managing patients.
What drugs can be used?
  • Oral doxycycline is a very effective drug. Most patients without serious organ involvement can be managed with this.
  • Chloramphenicol is preferred by many clinicians despite its grave side effects. It can be used in severe disease. Response seems to be dramatic, but there's no evidence to back its use. I myself has seen this being used on two patients with severe disease, both of whom survived!
    • What is the grave side effect of chloramphenicol?
The patient was started on doxycycline. Later IV chloramphenicol was added. Patient became afebrile in nearly two days and made a good recovery.




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