Submitted by Dr HP Shum (Department of Intensive Care, PYNEH) on 10 Mar 2009
F/66, good past health, attended AED because of dizziness, general malaise for 4 weeks, chill and rigor, abdominal discomfort with nausea. Recent travel to Hainan (海南島) 1 week ago, no significant animal/ bird contact. PE: T 38C, severe conjunctival congestion, multiple oral ulcers, macular rash over abdomen and back, 2 cm shallow ulcer over left infra-mammary region with darkened base.
Photos of our patient regrettably had not been obtained. The above photos of the eye and skin lesions were obtained from another patient with the same condition, and the appearance is very similar to ours.
Blood results: WCC 12.3 (neutrophil 12.1), Hb 13.1, HCT 0.375, PLT 23, INR 1.2, APTT 45.4, DD >1.0, Na <100, K 5.0, Ur 5.6, Cr 50, Bili 60.9, ALP 490, ALT 208; Urinalysis Blood 3+, Protein 2+; Microbiology results: Weil felix test OX2 /OX19/ OXK <1:20, dengue IgM –ve, Leptospirosis IgM –ve, Legionella pneumophilia <32, malaria screening –ve, mycoplasma <10, blood c/st –ve, urine c/st –ve, stool c/st –ve
What is the diagnosis?
Finally, orientia tsutsugamushi titer 512
Diagnosis: Scrub typhus
Special points:
1) conjunctival congestion and hyponatremia are common findings in patients with scrub typhus
2) Weil-Felix test based on cross reaction between anti-rickettsial Ab and Proteus Ag is neither specific nor sensitive
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2. Kato T et al. Jpn J Ophthalmol. 1997 May-Jun;41(3):196-9.
Conjunctival injection, episcleral vessel dilation, and subconjunctival hemorrhage in patients with new tsutsugamushi disease
3. Shichi D et al. Kansenshogaku Zasshi. 2008 Jul;82(4):335-40. Japanese
Hyponatremia occur in 4 out of 6 patients