Physical examination:
| GA: |
a febrile boy, alert and active, no pallor, no jaundice |
| V/S: |
body temp (axillary): 39.2 C, PR: 100-120/mins, RR: 28-30/min, BP 96/60 mmHg. |
| HEENT: |
injected conjunctiva both eyes without eyes discharge, no pale conjunctiva, no icteric sclera, no injected pharynx and tonsils. |
| Lymph node: |
non tender lymph nodes were palpable as the following:
bilateral cervical lymph nodes, size 0.8-1 cm. in diameter
bilateral axillary lymph nodes, size 1.5-2 cm. in diameter
bilateral inguinal lymph nodes, size 1 cm. in diameter |
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| Chest: |
trachea in midline, no retraction |
| Lung: |
clear, no adventitious sound |
| Heart: |
regular, no abnormal heart sound |
| Abdomen: |
normal contour, active bowel sound, no point of tenderness, liver can be palpable 6 cm. below RCM, liver span 13 cm., not tender, smooth surface, spleen just palpable below LCM. |
| Skin: |
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2 ulcerated lesions on clean erythrematous base without any crust were seen over his bilateral axillary regions as seen in figure 1 and 2 |
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1 ulcerated lesion on clean erythrematous base without any crust was seen over his right inguinal region, as seen in figure 3
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| the sizes were approximately 0.6-0.8 cm. in diameter. The lesions were not tender. |
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Figure 1 |
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Figure 2 |
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Figure 3 |
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| Neurological examination |
within normal limit |
Problem list:
| Active: |
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1. Subacute fever (10 days)
2. Three ulcerated skin lesions
3. Generalized lymphadenopathy
4. Hepatosplenomegaly |
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| Investigatons: |
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CBC:
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Hb 9.0 mg/dL, Hct 28.1 %, WBC 10,200 cells/cu.mm. (neutroplil 70%, lymphocyte 14%, monocyte 4%, atypical lymphocyte 8%), platlet count 152,000 cells/cu.mm. |
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Peripheral blood smear: negative for malaria. |
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U/A: no rbc, no wbc, pH 6, sp.gr. 1.010, negative for albumin and sugar. |
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CXR: unremarkable study. |
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ECG: normal sinus rhythm, no ST-T change. |
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IFA for scrub typhus: pending |
| Diagnosis : Scrub typhus in an infant with mild anemia (iron deficiency anemia) |
| Course in the hospital: |
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After the first dose of doxycycline 2.2 mg/kg/dose was given orally, the fever subsided. Doxycycline was continued for 5 days with the dose of 2.2mg/kg/day. |
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Later, the result of IFA for scrub typhus showed IgM titer >1:400, IgG titer 1:50 that confirmed the diagnosis of scrub typhus infection. |
Points to learn: |
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The presenting symptoms are non-specific. Fever is the most common and usually the only presenting symptom. Like the presenting symptoms, the clinical signs, namely fever, lymphadenopathy, hepatomegaly, splenomegaly, hyperemia of the conjunctivae and rash, are similarly nonspecific. |
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Eschar, present in 68% of the patients (ref 1), is a very useful sign in making the diagnosis. Although eschar was described as an ulcer, surrounded by a red areolar and often covered by a dark scab, one-third of the eschars in our children did not have the dark scab. They were found in moist intertriginous areas, such as the genitalia and the perineum. Although it is not common to find more than one eschar in each ptient, a few eschars in each patient have been reported (ref 1, 2). |
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By direct question: The parents remembered that the boy was bitten by insects before the episode of "fever". |
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The mother gave a good history that the skin lesions of her son had black crusts on top of the lesions which later peeled off before coming to our hoapital. |
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The response to doxycycline was excellent in this case as has been seen in other cases of scrub typhus without complications. |
| References: |
1. |
Sirisanthana V, Puthanakit T, Sirisanthana T. Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J 2003;22:341-5.  |
2. |
Sittiwangkul R, Pongprot Y, Silviliarat S, Oberdorfer P, Jittamala P, Sirisanthana V. Acute fulminant myocarditis in scrub typhus. Annals of Tropical Paediatrics 2008;28:14954. |
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