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|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 4 | Page : 1074-1075
Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation
Syed F Abbas, Ahmad Ozair, Vivek Kumar, D Himanshu
Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||16-Sep-2019|
|Date of Decision||10-Jul-2020|
|Date of Acceptance||17-Sep-2020|
|Date of Web Publication||2-Sep-2021|
Faculty of Medicine, King Georgefs Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Abbas SF, Ozair A, Kumar V, Himanshu D. Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation. Neurol India 2021;69:1074-5
We here present a case of scrub typhus (ST) manifesting with hemiparesis, which, to the best of our knowledge, has been reported few times prior. ST typically presents with headache, fever, cough, dyspnoea, and/or gastrointestinal symptoms., Early treatment ensures swift improvement. However, this common cause of febrile illness is often overlooked, even in endemic regions. This is due to a nonspecific presentation, low index of suspicion, and lack of diagnostic facilities., Even our institution, an apex public referral center of northern India, lacked affordable testing a decade ago. After testing began, a significant number of cases, which would have previously been labeled as “fever of unknown origin,” were found to be of ST and confirmed by response to doxycycline.
A 75-year-old male presented with acute-onset altered sensorium and left-sided hemiparesis, with a week's history of fever, productive cough, and breathlessness. While hemodynamically stable, he had bilateral crepitations with Glasgow Coma Scale of E4V3M4. There were bilateral flexor plantar responses, normal reflexes, absent neck rigidity, and no other neurological deficits. Other systems were unremarkable.
Initial investigations revealed leukocytosis, thrombocytopenia, stage-1 acute kidney injury, raised serum transaminases, and alkaline phosphatase. No derangements were present in serum electrolytes, bilirubin, albumin, and glucose. Cerebrospinal fluid (CSF) had protein 110 mg/dL, normal glucose (corresponding to plasma glucose), leucocyte count 30/mm3 with pleocytosis, and adenosine deaminase (ADA) 14.2 IU/L, raising suspicion of tubercular meningitis. CSF serology for dengue, Japanese encephalitis, Chikungunya, Herpes-Simplex virus, and India-Ink staining were all negative.
While conservative in-patient management continued, brain MRI revealed meningoencephalitis and diffusion restriction [Figure 1]. Anti-ST IgM antibodies by ELISA were positive, endorsing a diagnosis of ST as per Indian Council of Medical Research guidelines. Doxycycline administration resulted in rapid improvement.
|Figure 1: (a-c) Restricted diffusion on the right-sided temporo-parieto-occipital cortex on diffusion-weighted imaging, suggestive of encephalitis (arrows). (d and e) Leptomeningeal enhancement on an axial section of contrast-enhanced brain MRI, suggestive of meningitis (arrows)|
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The patient was discharged within a week, with normal renal and hepatic function. Follow-up revealed complete resolution without functional deficits.
This is one of the rare reported cases in literature of ST presenting with hemiparesis, which was secondary to either stroke. We have also seen ST paradoxically present as isolated lateral rectus palsy and intracerebral hemorrhage., Because ST can manifest with multiorgan dysfunction and/or death in cases of therapeutic delay, early diagnosis is critical.,
ST-induced meningitis or meningoencephalitis is reported in 14–83% of cases, with differential diagnoses being tubercular meningitis and cerebral malaria. CSF analysis, especially ADA levels and anti-ST IgM testing, is crucial in a nation where above etiologies are endemic.,
To conclude, serological testing for ST urgently needs to be made widely available pan-India.
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Conflicts of interest
There are no conflicts of interest.
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