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A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin.
Am J Dermatopathol. 2018 Oct; 40(10):767-771.AJ

Abstract

Scrub typhus is becoming a clinically important cause of acute undifferentiated febrile illness in Taiwan. The incubation period is between 6 and 21 days after exposure. It is transmitted by chiggers (larva of trombiculid mite) in long grasses and in dirt-floor homes, with infection characterized by a flu-like illness of fever, headache, and myalgia lasting approximately 1 week. It has various systemic manifestations, including GI symptoms. In some, the illness progresses to multiorgan dysfunction syndrome and death. We report on a 13-year-old boy who lived in Taipei City and who had initially tentative diagnosis of acute pyrexia of unknown origin with high fever up to 40.3°C for 1 week, but later had thrombocytopenia and diffuse abdominal pain with peritoneal sign suspected acute appendicitis. During the clinical course, septic shock and disseminated intravascular coagulopathy (DIC) were noted. There were skin rash in his trunk and extremities and an eschar with black crust surrounded by a scaling erythematous rim on his right buttock. In addition, we got the information of his travel history in Green Island and Orchid Island for 10 days.With the correct antibiotics, vancomycin, meropenem, and doxycycline, the patient was getting better and corresponding with high level of granulysin and tumor necrosis factor-alpha. The diagnosis of scrub typhus was confirmed by the biopsy of eschar and high quantitative real-time polymerase chain reaction values of Orientia tsutsugamushi (16sRNA and 56 kDa) tested by Centers for Disease Control and Prevention, Taiwan. Histopathological findings of the eschar revealed the leukocytoclastic vasculitis, crust and thrombus formation with many gram-negative microorganisms, O. tsutsugamushi demonstrated by 47 kDa monoclonal antibody immunohistochemical stain and electromicroscopy.

OUTCOMES

After the careful selection of appropriate antibiotics including meropenem, vancomycin, and doxycycline, he recovered and was subsequently discharged 7 days after admission.

LESSON SUBSECTIONS

This case highlights that scrub typhus infection can mimic acute abdomen and septic shock with DIC. This rare presentation of acute abdomen and septic shock with thrombocytopenia and DIC caused by scrub typhus should remind physicians to be alert to the possibility of acute abdomen and febrile illness resulting from scrub typhus.

Authors+Show Affiliations

School of Medicine, Taipei Medical University, Taipei, Taiwan. Department of Otolaryngology Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.Department of Dermatology, Cathay General Hospital, Taipei, Taiwan.Department of Pediatrics, Far-Eastern Memorial Hospital, New Taipei, Taiwan.Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan. School of Medicine, Fu Jen Catholic University, New Taipei, Taiwan.Department of Dermatology, Research Center of Cutaneous Disorders, Chung Shan Hospital, Taipei, Taiwan.Department of Dermatology, Chang Gung Memorial Hospital, Linko, Taipei, Taiwan.

Pub Type(s)

Case Reports
Journal Article
Review

Language

eng

PubMed ID

29697421

Citation

Chang, Po-Hsiung, et al. "A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin." The American Journal of Dermatopathology, vol. 40, no. 10, 2018, pp. 767-771.
Chang PH, Cheng YP, Chang PS, et al. A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin. Am J Dermatopathol. 2018;40(10):767-771.
Chang, P. H., Cheng, Y. P., Chang, P. S., Lo, C. W., Lin, L. H., Lu, C. F., & Chung, W. H. (2018). A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin. The American Journal of Dermatopathology, 40(10), 767-771. https://doi.org/10.1097/DAD.0000000000001167
Chang PH, et al. A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin. Am J Dermatopathol. 2018;40(10):767-771. PubMed PMID: 29697421.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A Case Report and Literature Review of Scrub Typhus With Acute Abdomen and Septic Shock in a Child-The Role of Leukocytoclastic Vasculitis and Granulysin. AU - Chang,Po-Hsiung, AU - Cheng,Yu-Pin, AU - Chang,Po-Sheng, AU - Lo,Chiao-Wei, AU - Lin,Lung-Huang, AU - Lu,Chin-Fang, AU - Chung,Wen-Hung, PY - 2018/4/27/pubmed PY - 2019/1/8/medline PY - 2018/4/27/entrez SP - 767 EP - 771 JF - The American Journal of dermatopathology JO - Am J Dermatopathol VL - 40 IS - 10 N2 - : Scrub typhus is becoming a clinically important cause of acute undifferentiated febrile illness in Taiwan. The incubation period is between 6 and 21 days after exposure. It is transmitted by chiggers (larva of trombiculid mite) in long grasses and in dirt-floor homes, with infection characterized by a flu-like illness of fever, headache, and myalgia lasting approximately 1 week. It has various systemic manifestations, including GI symptoms. In some, the illness progresses to multiorgan dysfunction syndrome and death. We report on a 13-year-old boy who lived in Taipei City and who had initially tentative diagnosis of acute pyrexia of unknown origin with high fever up to 40.3°C for 1 week, but later had thrombocytopenia and diffuse abdominal pain with peritoneal sign suspected acute appendicitis. During the clinical course, septic shock and disseminated intravascular coagulopathy (DIC) were noted. There were skin rash in his trunk and extremities and an eschar with black crust surrounded by a scaling erythematous rim on his right buttock. In addition, we got the information of his travel history in Green Island and Orchid Island for 10 days.With the correct antibiotics, vancomycin, meropenem, and doxycycline, the patient was getting better and corresponding with high level of granulysin and tumor necrosis factor-alpha. The diagnosis of scrub typhus was confirmed by the biopsy of eschar and high quantitative real-time polymerase chain reaction values of Orientia tsutsugamushi (16sRNA and 56 kDa) tested by Centers for Disease Control and Prevention, Taiwan. Histopathological findings of the eschar revealed the leukocytoclastic vasculitis, crust and thrombus formation with many gram-negative microorganisms, O. tsutsugamushi demonstrated by 47 kDa monoclonal antibody immunohistochemical stain and electromicroscopy. OUTCOMES: After the careful selection of appropriate antibiotics including meropenem, vancomycin, and doxycycline, he recovered and was subsequently discharged 7 days after admission. LESSON SUBSECTIONS: This case highlights that scrub typhus infection can mimic acute abdomen and septic shock with DIC. This rare presentation of acute abdomen and septic shock with thrombocytopenia and DIC caused by scrub typhus should remind physicians to be alert to the possibility of acute abdomen and febrile illness resulting from scrub typhus. SN - 1533-0311 UR - https://www.unboundmedicine.com/medline/citation/29697421/A_Case_Report_and_Literature_Review_of_Scrub_Typhus_With_Acute_Abdomen_and_Septic_Shock_in_a_Child_The_Role_of_Leukocytoclastic_Vasculitis_and_Granulysin_ L2 - https://doi.org/10.1097/DAD.0000000000001167 DB - PRIME DP - Unbound Medicine ER -