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Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India.
PLoS Negl Trop Dis 2014; 8(1):e2605PN

Abstract

BACKGROUND

Infection-related acute kidney injury (AKI) is an important preventable cause of morbidity and mortality in the tropical region. The prevalence and outcome of kidney involvement, especially AKI, in scrub typhus is not known. We investigated all patients with undiagnosed fever and multisystem involvement for scrub typhus and present the pattern of renal involvement seen.

METHODS

From September 2011 to November 2012, blood samples of all the patients with unexplained acute febrile illness and/or varying organ involvement were evaluated for evidence of scrub typhus. A confirmed case of scrub typhus was defined as one with detectable Orientia tsutsugamushi deoxyribonucleic acid (DNA) in patient's blood sample by nested polymerase chain reaction (PCR) targeting the gene encoding 56-kDa antigen and without any alternative etiological diagnosis. Renal involvement was defined by demonstration of abnormal urinalysis and/or reduced glomerular filtration rate. AKI was defined as per Kidney Disease: Improving Global Outcomes (KDIGO) definition.

RESULTS

Out of 201 patients tested during this period, 49 were positive by nested PCR for scrub typhus. Mean age of study population was 34.1±14.4 (range 11-65) years. Majority were males and a seasonal trend was evident with most cases following the rainy season. Overall, renal abnormalities were seen in 82% patients, 53% of patients had AKI (stage 1, 2 and 3 in 10%, 8% and 35%, respectively). The urinalysis was abnormal in 61%, with dipstick positive albuminuria (55%) and microscopic hematuria (16%) being most common. Acute respiratory distress syndrome (ARDS) and shock were seen in 57% and 16% of patients, respectively. Hyperbilirubinemia was associated with AKI (p = 0.013). A total of 8 patients (including three with dialysis dependent AKI) expired whereas rest all made uneventful recovery. Jaundice, oliguria, ARDS and AKI were associated with mortality. However, after multivariate analysis, only oliguric AKI remained a significant predictor of mortality (p = 0.002).

CONCLUSIONS

Scrub typhus was diagnosed in 24% of patients presenting with unexplained febrile illness according to a strict case definition not previously used in this region. Renal abnormalities were seen in almost 82% of all patients with evidence of AKI in 53%. Our finding is contrary to current perception that scrub typhus rarely causes renal dysfunction. We suggest that all patients with unexplained febrile illness be investigated for scrub typhus and AKI looked for in scrub typhus patients.

Authors+Show Affiliations

Departments of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Departments of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Departments of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Departments of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Pulmonary and Critical Care Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.Departments of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India ; George Institute for Global Health, New Delhi, India.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

24498445

Citation

Kumar, Vivek, et al. "Scrub Typhus Is an Under-recognized Cause of Acute Febrile Illness With Acute Kidney Injury in India." PLoS Neglected Tropical Diseases, vol. 8, no. 1, 2014, pp. e2605.
Kumar V, Kumar V, Yadav AK, et al. Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India. PLoS Negl Trop Dis. 2014;8(1):e2605.
Kumar, V., Kumar, V., Yadav, A. K., Iyengar, S., Bhalla, A., Sharma, N., ... Jha, V. (2014). Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India. PLoS Neglected Tropical Diseases, 8(1), pp. e2605. doi:10.1371/journal.pntd.0002605.
Kumar V, et al. Scrub Typhus Is an Under-recognized Cause of Acute Febrile Illness With Acute Kidney Injury in India. PLoS Negl Trop Dis. 2014;8(1):e2605. PubMed PMID: 24498445.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India. AU - Kumar,Vivek, AU - Kumar,Vinod, AU - Yadav,Ashok K, AU - Iyengar,Sreenivasa, AU - Bhalla,Ashish, AU - Sharma,Navneet, AU - Aggarwal,Ritesh, AU - Jain,Sanjay, AU - Jha,Vivekanand, Y1 - 2014/01/30/ PY - 2013/07/24/received PY - 2013/11/10/accepted PY - 2014/2/6/entrez PY - 2014/2/6/pubmed PY - 2014/9/10/medline SP - e2605 EP - e2605 JF - PLoS neglected tropical diseases JO - PLoS Negl Trop Dis VL - 8 IS - 1 N2 - BACKGROUND: Infection-related acute kidney injury (AKI) is an important preventable cause of morbidity and mortality in the tropical region. The prevalence and outcome of kidney involvement, especially AKI, in scrub typhus is not known. We investigated all patients with undiagnosed fever and multisystem involvement for scrub typhus and present the pattern of renal involvement seen. METHODS: From September 2011 to November 2012, blood samples of all the patients with unexplained acute febrile illness and/or varying organ involvement were evaluated for evidence of scrub typhus. A confirmed case of scrub typhus was defined as one with detectable Orientia tsutsugamushi deoxyribonucleic acid (DNA) in patient's blood sample by nested polymerase chain reaction (PCR) targeting the gene encoding 56-kDa antigen and without any alternative etiological diagnosis. Renal involvement was defined by demonstration of abnormal urinalysis and/or reduced glomerular filtration rate. AKI was defined as per Kidney Disease: Improving Global Outcomes (KDIGO) definition. RESULTS: Out of 201 patients tested during this period, 49 were positive by nested PCR for scrub typhus. Mean age of study population was 34.1±14.4 (range 11-65) years. Majority were males and a seasonal trend was evident with most cases following the rainy season. Overall, renal abnormalities were seen in 82% patients, 53% of patients had AKI (stage 1, 2 and 3 in 10%, 8% and 35%, respectively). The urinalysis was abnormal in 61%, with dipstick positive albuminuria (55%) and microscopic hematuria (16%) being most common. Acute respiratory distress syndrome (ARDS) and shock were seen in 57% and 16% of patients, respectively. Hyperbilirubinemia was associated with AKI (p = 0.013). A total of 8 patients (including three with dialysis dependent AKI) expired whereas rest all made uneventful recovery. Jaundice, oliguria, ARDS and AKI were associated with mortality. However, after multivariate analysis, only oliguric AKI remained a significant predictor of mortality (p = 0.002). CONCLUSIONS: Scrub typhus was diagnosed in 24% of patients presenting with unexplained febrile illness according to a strict case definition not previously used in this region. Renal abnormalities were seen in almost 82% of all patients with evidence of AKI in 53%. Our finding is contrary to current perception that scrub typhus rarely causes renal dysfunction. We suggest that all patients with unexplained febrile illness be investigated for scrub typhus and AKI looked for in scrub typhus patients. SN - 1935-2735 UR - https://www.unboundmedicine.com/medline/citation/24498445/Scrub_typhus_is_an_under_recognized_cause_of_acute_febrile_illness_with_acute_kidney_injury_in_India_ L2 - http://dx.plos.org/10.1371/journal.pntd.0002605 DB - PRIME DP - Unbound Medicine ER -