Case Report
Scrub typhus with visual hallucinations Sanjay K Mahajan1, Madan Kaushik1, Rajiv Raina2, Ravi C Sharma3, Preyander Thakur4 and Jai Bharat Sharma4
Tropical Doctor 2015, Vol. 45(2) 146–147 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514565426 tdo.sagepub.com
Abstract The occurrence of psychiatric symptoms in scrub typhus is not commonly reported in literature. We present a case of scrub typhus with visual hallucinations.
Keywords Rickettsial diseases, psychosis, Orientia tsutsugamushi, Himachal Pradesh
Introduction Scrub typhus is a zoonotic febrile illness caused by Orientia tsutsugamushi. This disease is now re-emerging in many areas of the world including India. Symptoms are usually fever, severe headache with body aches, with signs of lymphadenopathy, hepato-splenomegaly and rash. An ‘eschar’ may be present in 50% of cases and is pathognomic of this disease.1 However, the presentation of scrub typhus can be variable. Previous documentation of scrub typhus in our area exists.2 The diagnosis is sometimes difficult but demonstration of IgM antibodies by ELISA has a high sensitivity and specificity.
Case Report A 63-year-old woman presented with fever, diffuse headache and body aches for the previous 10 days. She had dyspnoea for 4 days. There was no history of an altered sensorium or altered behaviour at the time of admission. On examination, she was febrile, conscious, oriented in time, place and person. She was tachycardic at 120/min, normotensive, tachypnoic at 30/min and her oxygen saturation was low at 84%. An eschar was noted on the abdomen (Figure 1). Crepitations were noted in bilateral infrascapular regions. Relevant laboratory investigations showed a raised erythrocyte sedimentation rate of 54 (n ¼ 20), mild derangement of hepatic function, hypoalbuminaemia of 24 mg/L (n > 35 mg/L), and impaired renal function (serum creatinine of 4.2 mmol/L: n < 0.22 mmol/L. Rest of the systemic examination was normal. In view of the presence of the eschar she was empirically treated with doxycycline, intravenous fluids and
oxygen therapy. The diagnosis of scrub typhus was confirmed by IgM antibodies (InBios). Other investigations for typhoid and malaria, together with blood and urine culture were all negative, and her chest radiograph and abdominal ultrasound showed no abnormality. The patient’s general condition improved and her symptoms and signs disappeared over the next 72 h. However, on the sixth day of admission, she suffered two episodes of visual hallucinations of acute onset, perceiving animals and dead relatives; she was alert but confused. There was no other neurological deficit noted. Her laboratory tests had normalised and stay thus. A cerebrospinal fluid (CSF) examination during one such episode was likewise normal. The hallucinatory symptoms lasted for 12 h. Upon further questioning, her son, who denied any previous depressive or psychotic symptoms, recalled a similar episode which lasted for 8–10 h 4 days after start this illness. The remaining course of her hospital stay remained uneventful and our patient was discharged on the 10th day with advice to complete her doxycycline of 2 weeks. She remained physically and mentally asymptomatic on follow-up 3 months after discharge. 1 Assistant Professor, Department of Medicine, I. G. Medical College, Shimla, Himachal Pradesh, India 2 Professor, Department of Medicine, I. G. Medical College, Shimla, Himachal Pradesh, India 3 Professor and Head, Department of Psychiatry, I. G. Medical College, Shimla, Himachal Pradesh, India 4 Resident, Department of Medicine, I. G. Medical College, Shimla, Himachal Pradesh, India
Corresponding author: Sanjay K Mahajan, 25/3, U. S. Club, Shimla, Himachal Pradesh, 171001 India. Email: [email protected]
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Mahajan et al.
147 meningitis and encephalitis if accompanied by renal insufficiency and/or jaundice.4,5 Thus alteration in the consciousness of a patient of scrub typhus can be attributed to multiple factors. The classic changes in consciousness have been described as delirium similar to other rickettsial and bacterial febrile illnesses.1,3,5,6 In delirium, however, abnormal behaviour is also associated with changes in consciousness levels. It is different from other psychotic conditions where abnormal behaviour is seen with impaired insight but without alteration in consciousness. The presence of psychiatric disturbances towards the end of the first week of illness is also known to occur in epidemic typhus, another rickettsial illness.6 However, occurrence of neuropsychiatric manifestations in scrub typhus has not been commonly reported.7,8 Our patient clearly showed two episodes of visual hallucinations during the course of her illness each lasting for 10–12 h. She never suffered subsequent hallucinations.
Figure 1. Photograph showing eschar on abdomen.
Declaration of conflicting interests None declared.
Discussion
Funding
The word ‘typhus’ is derived from Greek word ‘u’o&’, meaning clouding of consciousness. Scrub typhus is known to cause disseminated disease involving various organs of body including the central nervous system. The presence of hypoxia, hypotension, hepatic and renal impairments are typical of this disease.3 There is a varying degree of involvement of the central nervous system in almost all patients but rarely with focal damage; however, few objective neurological signs are usually seen during the encephalitis stage. In some cases tremors, delirium, nervousness, slurred speech, deafness or neck rigidity may develop in the second week of illness. The disease can present occasionally with focal neurological signs such as quadriparesis, dysphagia, bilateral gaze evoked nystagmus, anarthria, and bilateral sixth and seventh nerve palsies. The presence of a sensory level at thoracic cord and sensori-neural auditory loss has also been reported.4 The presence of hearing loss concurrent with fever is reported by as many as one-third of patients and is a useful diagnostic clue in endemic areas.1 Patients may present with meningitis and/or encephalitis, becoming delirious, agitated and sometimes with epileptic seizure. The CSF profile may show changes similar to viral or tuberculous meningitis. Scrub typhus should also be suspected in patients living in endemic areas as a differential diagnosis of aseptic
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Watt G. Scrub typhus. In: Warrel DA, Cox TM, Firth JD, et al. (eds) Oxford Textbook of Medicine, 4th edn. Oxford: Oxford University Press, 2003, pp.629–631. 2. Mahajan SK, Rolain J-M, Kashyap R, Bakshi D, Sharma V, Prasher BS, et al.. Scrub typhus in Himalayas. Emerg Infect Dis 2006; 12: 1590–1592. 3. Cowans GO. Rickettsial infections. In: Cook GC and Zumla A (eds) Manson’s Tropical Diseases, 21st edn. London: Elsevier, 2003, pp.891–90. 4. Mahajan SK, Rolain J-M, Kanga A and Raoult D. Scrub typhus involving central nervous system, India, 2004–2006. Emerg Infect Dis 2010; 16: 1641–1642. 5. Mahajan SK. Scrub typhus. J Assoc Physic India 2005; 53: 954–958. 6. Gulati S and Maheshwari A. Neurological manifestations of scrub typhus. Ann Indian Acad Neurol 2013; 16: 131. 7. Ripley HS. Neuropsychiatric observations of tsutsugamushi typhus (scrub typhus). Arch Neur Psych 1946; 56: 42–54. 8. Wisseman CL. Rickettsial infections. In: Strickland GT (ed). Hunter’s tropical medicine, 7th edn. Philadelphia, PA: WB Saunders, 1991, pp.256–289.
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Scrub typhus with visual hallucinations Sanjay K Mahajan1, Madan Kaushik1, Rajiv Raina2, Ravi C Sharma3, Preyander Thakur4 and Jai Bharat Sharma4
Tropical Doctor 2015, Vol. 45(2) 146–147 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514565426 tdo.sagepub.com
Abstract The occurrence of psychiatric symptoms in scrub typhus is not commonly reported in literature. We present a case of scrub typhus with visual hallucinations.
Keywords Rickettsial diseases, psychosis, Orientia tsutsugamushi, Himachal Pradesh
Introduction Scrub typhus is a zoonotic febrile illness caused by Orientia tsutsugamushi. This disease is now re-emerging in many areas of the world including India. Symptoms are usually fever, severe headache with body aches, with signs of lymphadenopathy, hepato-splenomegaly and rash. An ‘eschar’ may be present in 50% of cases and is pathognomic of this disease.1 However, the presentation of scrub typhus can be variable. Previous documentation of scrub typhus in our area exists.2 The diagnosis is sometimes difficult but demonstration of IgM antibodies by ELISA has a high sensitivity and specificity.
Case Report A 63-year-old woman presented with fever, diffuse headache and body aches for the previous 10 days. She had dyspnoea for 4 days. There was no history of an altered sensorium or altered behaviour at the time of admission. On examination, she was febrile, conscious, oriented in time, place and person. She was tachycardic at 120/min, normotensive, tachypnoic at 30/min and her oxygen saturation was low at 84%. An eschar was noted on the abdomen (Figure 1). Crepitations were noted in bilateral infrascapular regions. Relevant laboratory investigations showed a raised erythrocyte sedimentation rate of 54 (n ¼ 20), mild derangement of hepatic function, hypoalbuminaemia of 24 mg/L (n > 35 mg/L), and impaired renal function (serum creatinine of 4.2 mmol/L: n < 0.22 mmol/L. Rest of the systemic examination was normal. In view of the presence of the eschar she was empirically treated with doxycycline, intravenous fluids and
oxygen therapy. The diagnosis of scrub typhus was confirmed by IgM antibodies (InBios). Other investigations for typhoid and malaria, together with blood and urine culture were all negative, and her chest radiograph and abdominal ultrasound showed no abnormality. The patient’s general condition improved and her symptoms and signs disappeared over the next 72 h. However, on the sixth day of admission, she suffered two episodes of visual hallucinations of acute onset, perceiving animals and dead relatives; she was alert but confused. There was no other neurological deficit noted. Her laboratory tests had normalised and stay thus. A cerebrospinal fluid (CSF) examination during one such episode was likewise normal. The hallucinatory symptoms lasted for 12 h. Upon further questioning, her son, who denied any previous depressive or psychotic symptoms, recalled a similar episode which lasted for 8–10 h 4 days after start this illness. The remaining course of her hospital stay remained uneventful and our patient was discharged on the 10th day with advice to complete her doxycycline of 2 weeks. She remained physically and mentally asymptomatic on follow-up 3 months after discharge. 1 Assistant Professor, Department of Medicine, I. G. Medical College, Shimla, Himachal Pradesh, India 2 Professor, Department of Medicine, I. G. Medical College, Shimla, Himachal Pradesh, India 3 Professor and Head, Department of Psychiatry, I. G. Medical College, Shimla, Himachal Pradesh, India 4 Resident, Department of Medicine, I. G. Medical College, Shimla, Himachal Pradesh, India
Corresponding author: Sanjay K Mahajan, 25/3, U. S. Club, Shimla, Himachal Pradesh, 171001 India. Email: [email protected]
Downloaded from tdo.sagepub.com by guest on November 19, 2015
Mahajan et al.
147 meningitis and encephalitis if accompanied by renal insufficiency and/or jaundice.4,5 Thus alteration in the consciousness of a patient of scrub typhus can be attributed to multiple factors. The classic changes in consciousness have been described as delirium similar to other rickettsial and bacterial febrile illnesses.1,3,5,6 In delirium, however, abnormal behaviour is also associated with changes in consciousness levels. It is different from other psychotic conditions where abnormal behaviour is seen with impaired insight but without alteration in consciousness. The presence of psychiatric disturbances towards the end of the first week of illness is also known to occur in epidemic typhus, another rickettsial illness.6 However, occurrence of neuropsychiatric manifestations in scrub typhus has not been commonly reported.7,8 Our patient clearly showed two episodes of visual hallucinations during the course of her illness each lasting for 10–12 h. She never suffered subsequent hallucinations.
Figure 1. Photograph showing eschar on abdomen.
Declaration of conflicting interests None declared.
Discussion
Funding
The word ‘typhus’ is derived from Greek word ‘u’o&’, meaning clouding of consciousness. Scrub typhus is known to cause disseminated disease involving various organs of body including the central nervous system. The presence of hypoxia, hypotension, hepatic and renal impairments are typical of this disease.3 There is a varying degree of involvement of the central nervous system in almost all patients but rarely with focal damage; however, few objective neurological signs are usually seen during the encephalitis stage. In some cases tremors, delirium, nervousness, slurred speech, deafness or neck rigidity may develop in the second week of illness. The disease can present occasionally with focal neurological signs such as quadriparesis, dysphagia, bilateral gaze evoked nystagmus, anarthria, and bilateral sixth and seventh nerve palsies. The presence of a sensory level at thoracic cord and sensori-neural auditory loss has also been reported.4 The presence of hearing loss concurrent with fever is reported by as many as one-third of patients and is a useful diagnostic clue in endemic areas.1 Patients may present with meningitis and/or encephalitis, becoming delirious, agitated and sometimes with epileptic seizure. The CSF profile may show changes similar to viral or tuberculous meningitis. Scrub typhus should also be suspected in patients living in endemic areas as a differential diagnosis of aseptic
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Watt G. Scrub typhus. In: Warrel DA, Cox TM, Firth JD, et al. (eds) Oxford Textbook of Medicine, 4th edn. Oxford: Oxford University Press, 2003, pp.629–631. 2. Mahajan SK, Rolain J-M, Kashyap R, Bakshi D, Sharma V, Prasher BS, et al.. Scrub typhus in Himalayas. Emerg Infect Dis 2006; 12: 1590–1592. 3. Cowans GO. Rickettsial infections. In: Cook GC and Zumla A (eds) Manson’s Tropical Diseases, 21st edn. London: Elsevier, 2003, pp.891–90. 4. Mahajan SK, Rolain J-M, Kanga A and Raoult D. Scrub typhus involving central nervous system, India, 2004–2006. Emerg Infect Dis 2010; 16: 1641–1642. 5. Mahajan SK. Scrub typhus. J Assoc Physic India 2005; 53: 954–958. 6. Gulati S and Maheshwari A. Neurological manifestations of scrub typhus. Ann Indian Acad Neurol 2013; 16: 131. 7. Ripley HS. Neuropsychiatric observations of tsutsugamushi typhus (scrub typhus). Arch Neur Psych 1946; 56: 42–54. 8. Wisseman CL. Rickettsial infections. In: Strickland GT (ed). Hunter’s tropical medicine, 7th edn. Philadelphia, PA: WB Saunders, 1991, pp.256–289.
Downloaded from tdo.sagepub.com by guest on November 19, 2015
