Clinical study &
laborotory profile of rickettsial fever in children- a study from rural
Maharashtra
Sunil S. Vaidya1, Atul A.
Kulkarni2
1Professor, Dept. of Pediatrics, Ashwini Rural Medical College,
Hospital & Research centre, Kumbhari, Solapur (Maharashtra), 2Assistant Professor, Dept. of Pediatrics, Ashwini Rural Medical
College, Hospital & Research Centre, Kumbhari, Solapur,
Maharashtra, India
Address for
correspondence: Dr Sunil S. Vaidya, Email:
drsvaidya@gmail.com
Abstract
Introduction:
Rickettsial fever has been reported to be endemic in the Himalayan
belt, Maharashtra and Karnataka in India among the adult population.
Pediatric data on the same is limited in developing countries.
Recently, the profile of rickettsial fever has been described in
children in South India with similar clinical features. Material Methods:
This study was conducted from the patients admitted in our hospital,
Ashwini Rural Medical College, Hospital & RC, Solapur, from the
month of January 2014 to June 2015.The inclusion criteria were,
clinical suspicion & supportive lab evidence – Weil
Felix, positive leucocytosis, thrombocytopenia. Results: In our
study age of presentation ranged from 6 months to 12 years, with mean
age of 7 yrs, there was no statistically significant sex difference.
All patients presented with fever & purpuric rash was seen in
82%, altered sensorium was seen in 58 %, seizures were seen 34%
& Hepatosplenomegaly was seen in 65 % of cases. Other
investigations: In our study CSF examination was done in 25 patients of
which 10 had abnormal findings, 6 showed low sugar and 8 high protein.
In our study according to the Weil Felix titers, most probable disease
would be tick borne spotted fever or epidemic typhus, since no louse
infestation (the scalp and body infestation, lymphadenopathy) was seen
in any of the patients, and most of them were from rural areas more
chances of tick infestation. Conclusions:
The diagnosis of rickettsia should always be kept in mind for workup of
exanthematous fever. High index of clinical suspicion and good
laboratory co- relation are helpful in detection of more no of cases.
Early diagnosis and treatment with doxy and chloramphenicol can reduce
the hospital stay and cost. Associated mixed infections may mislead
diagnosis and are more fatal. Weil Felix test is not diagnostic
standard. It should be interpreted in good clinical context, still it
is easily available to all & remains good screening test.
Key words:
Rickettsial Fever, Weil Felix Test, Rash, Hepatosplenomegal
Manuscript received: 24th
June 2016, Reviewed:
4th July 2016
Author Corrected; 15th
July 2016, Accepted for
Publication: 30th July 2016
Introduction
Microorganisms belong to the family of rickettsiaceae and are obligate
intracellular cocco-bacilli [1]. The causative organism was named after
Howard Ricketts, who was the first to demonstrate the role of the tick
(Dermacentor andersonii) as the vector for the disease in western
Montana in the US in 1906 [2]. The illnesses caused can be divided into
3 main biogroups – Spotted fever, typhus and scrub typhus
groups [3]. The most frequent presenting symptoms of the illness
include fever, headache, rash, and myalgias [4]. Rickettsial fever has
been reported to be endemic in the Himalayan belt, Maharashtra and
Karnataka in India among the adult population [5]. Pediatric data on
the same is limited in developing countries. Recently, the profile of
rickettsial fever has been described in children in South India with
similar clinical features [6].
Rickettsial fever is an acute febrile zoonotic disease spread by bites
of ticks and mites. Rickettsiae make up a family of gram – ve
coccobaccilli and short bacilli that grow strictly in eukaryotic cells.
They are obligate intracellular parasites. Humans are accidental host.
The family rickettsiae is named after Howard Taylor Ricketts who
discovered spotted fever and died during his studies (1909). The family
has been classified in 4 genera as Rickettsia, Coxiella, Rochemalia
& Erhlichia [7], [8].
Rickettsia have varied clinical spectrum of manifestations, including
the CNS, RS, and GIT. Early Clinical diagnosis with high index of
suspicion can prevent morbidity & mortality. Prevalence of this
disease is worldwide and in recent times increased incidence in India.
The varied clinical spectrum, lack of clinical suspicion, absence of
adequate laboratory techniques, expensive tests, all these pose a great
challenge in diagnosis and treatment[9], [10].
Rickettsial disease can be dangerous if missed. We have notice
increased incidence in the past 10 years. Thus we conducted a study to
evaluate the clinical data of patients suffering from it and admitted
to our hospital. This study aims to increase clinical suspicion,
awareness about laboratory evaluations, and treatment of rickettsial
infections.
Type of study: Retrospective
study
Methodology: This study was conducted from the patients admitted in our
hospital, Ashwini Rural Medical College, Hospital & RC,
Solapur, from the month of January 2014 to June 2015.
The inclusion criteria were:
1. clinical suspicion
2. supportive lab evidence – Weil Felix, positive
leucocytosis, thrombocytopenia,
• Clinical Suspicion was based
on history of fever, non confluent maculopapular or purpuric rash
involving palms and soles, and neurological symptoms.
• Weil Felix test for (OX-19,
0X-2, 0X-K strains) was done on each patient of clinical suspicion. It
is a slide agglutination test done according to
manufacturer’s instructions, from Plasmatech laboratories,
Bridfort, UK. The kit tests serum dilutions from 1:20 to 1:320.
Significant titre is 1:80, those with positive titre were included in
our study.
On admission, data of age, sex, local residing area, exposure to
animals, etc was recorded and, -complete blood count, -malarial
parasite, -urine exam. was done on all patients. CSF, electrolytes,
chest –X-ray, USG, dengue IgM, CT scan done as and when
needed. All patients were treated with: chloramphenicol (100 mg/kg/day)
in 3 divided doses.or doxycycline (5 mg/kg/day) as single dose or in
some cases both drugs were given.
Results
In our study of 9 months period, 60 patients satisfied our inclusion
criteria, age ranged from 6 months to 12 years, maximum incidence in 2
to 7 years age group (70%), and male to female ratio was 1.2:1.
Table No-1: Major
presenting symptoms
|
Sr.
no.
|
Clinical
features
|
No.
of cases
|
Percentage
%
|
|
1
|
Fever
|
60
|
100
|
|
2
|
Hepatosplenomegaly
|
39
|
65
|
|
3
|
GI upset
|
15
|
25
|
|
4
|
Convulsions
|
20
|
34
|
|
5
|
Altered
sensorium
|
35
|
58
|
|
6
|
Pain in
legs
|
6
|
10
|
|
7
|
Purpuric rash
|
49
|
82
|
|
8
|
Upper GI
bleeding
|
4
|
7
|
|
9
|
Pneumonia
|
3
|
5
|
Table No-2:
Investigations
|
INV
|
Value
|
No
|
%
|
|
Mean HB
|
9.3%
|
|
|
|
Leucocytosis
|
> 10,000 cell/mm
|
40
|
66
|
|
Thrombocytopenia
|
>100,000
|
33
|
56
|
CBC-Mean Hb was 9.3 gm/dl; Leucocytosis (>10,000 cells/mm) in
66%, thrombocytopenia (<1 lakh) was seen in 56%.
CSF analysis done in 25 patients of which 10 were abnormal, sugar low
in 6 cases, proteins high in 8 cases, pleocytosis in all cases with
mean cell count 78 cells/mm.
Table No-3: CSF analysis
|
CSF feature
|
No
|
%
|
|
Sugar low
|
6
|
10
|
|
Protein high
|
8
|
13
|
|
Pleocytosis
|
60
|
100
|
Other lab parameters:
Coagulation studies-
PT.APTT was prolonged in 5 out of 20 cases, FDP D Dimer was positive in
4 cases.
Echocardiography
– was done in 10 cases exhibiting tachycardia with gallop
rhythm, 5 of them showed myocardial involvement in form of reduced
EF<50%.
CT/MRI- scan
was done in 18 patients, of which 8 were normal, 7 had cerebral edema,
and 3 with features of meningitis.
Outcome- 5 children required mechanical ventilation, out of it 3
expired and 2 recovered well. Responses to doxy, chloramphenicol was
quite good and most were afebrile by 48-72 hours. Out of total 60 cases
55 (92%) recovered well, 7% expired and 3 cases went AMA.
Discussion
Rickettsial diseases are an important but often under recognized cause
of febrile illness locally. Of the wide range of rickettsial diseases,
typhus disease is the most commonly recognized entity in our area.
In our study age of presentation ranged from 6 months to 12 years, with
mean age of 7 yrs , there was no statistically significant sex
difference. This is similar to Colomba et.al[11] & Nigwekar P
et. a l [12] who showed median age of 5yrs and 6 yrs respectively with
no significant sex deference.
Majority of patients presented with fever (100%), purpuric rash was
seen in 82%, which is similar to Colomba et.al [11] & Nigwekar
P et. al[12]. Altered sensorium was seen in 58 % which is much more as
compared with Mahajan et. al[13]. (24%) &. Seizures were seen
34% in comparison to Mahajan et. al[13]. (19%) & Nigwekar P et.
al[12]. (36%). Hepatosplenomegaly was seen in 65 % as compared with
Mahajan et.al[13]. (43%) & Nigwekar P et. al[12]. (34%).
Other investigations: In our study CSF examination was done in 25
patients of which 10 had abnormal findings, 6 showed low sugar and 8
high protein. This proves CNS involvement in rickettsial fever.
In our study according to the Weil Felix titers, most probable disease
would be tick borne spotted fever or epidemic typhus, since no louse
infestation (the scalp and body infestation, lymphadenopathy) was seen
in any of the patients, and most of them were from rural areas more
chances of tick infestation. Hence tick borne spotted fever is most
likely cause but still further definitive investigations like PCR
should be done to detect the different rickettsial organisms.
Weil Felix test still remains the most commonly used serological test.
It may give false positive reactions with Proteus sp., Leptospirosis,
Borrelia and severe liver disease. It is negative for R.pox, R.
quintana, with brill- zinsser disease. Even though sensitivity and WF
test is low there are several reports which suggest good co-relation of
it with clinical suspicion and other tests. Immunoflourence Assay is
taken as gold standard test as it is most sensitive and most specific,
but it is too costly for us and even not available easily.
The patients with late presentation were in altered sensorium, with
predominant neurological features. They had poor outcome as compared to
those who had received doxycycline prophylactically.
Conclusions
Rickettsial fever does exist in our area and its incidence is rising.
The diagnosis of rickettsia should always be kept in mind for workup of
exanthematous fever. High index of clinical suspicion and good
laboratory co- relation are helpful in detection of more no of cases.
Early diagnosis and treatment with doxy and chloramphenicol can reduce
the hospital stay and cost. Associated mixed infections may mislead
diagnosis and are more fatal. Weil Felix test is not diagnostic
standard. It should be interpreted in good clinical context, still it
is easily available to all & remains good screening test.Use of
empirical treatment may be considered to reduce the morbidity and
mortality observed with this disease.
Funding:
Nil, Conflict of
interest: Nil
Permission from IRB:
Yes
References
1. Walker DH. Rickettsiae and rickettsial infections: the current state
of knowledge. Clin Infect Dis. 2007 oct;45 1:S39-44. [PubMed]
2. Ricketts HT. A micro-organism which apparently has a specific
relationship to Rocky Mountain spotted fever. JAMA 1909;52: 379
–380. [PubMed]
3. Jensenius M, Fournier P, Raoult D. Rickettsioses and the
international traveler. Clin Infect Dis. 2004;34(10):1493-9. [PubMed]
4. Helmick CG, Bernard KW, D'Angelo LJ. Rocky Mountain spotted fever:
clinical, laboratory, and epidemiological features of 262 cases. J
Infect Dis. 1984 Oct;150(4):480–488. [PubMed]
5. Padbidri VS, Gupta NP. Rickettsiosis in India: A review. J Indian
Med Assoc 1978; 71: 104-107. [PubMed]
6. N. Murali, Swathi Pillai, Thomas Cherian, P. Raghupathy, V. Padmini,
Elizabeth Mathai. Rickeetsial infections in South India: How to spot
the spotted fever. Indian Pediatrics 2001; 38: 1393-1396. [PubMed]
7. Raoult D, Parola P, editors. Rickettsial Diseases. New York: Informa
Healthcare USA 2007. [PubMed]
8. Frieden IJ, Resnick SD. Childhood exanthems – old and new.
Pediatr Clin N Am. 1991; 38: 859-887. [PubMed]
9. Reller ME, Dumler SJ. Nelson text book of pediatric. 19th ed.
Epidemic Typhus (Rickettsia prowazekii); 222.2: 1047-8.
10. Rathi N.,Rathi A. Indian Pediatrics: 2010 Feb;l47:159. [PubMed]
11. Colomba C, Laura S, Valentino FP, Raffaella R, Lucio T.
Mediterranean spotted fever: clinical and laboratory characteristics of
415 Sicilian children. BMC Infect Dis. 2006;6: 60. [PubMed]
12. Nigwekar P, Kavar Y, Shrikhande DY, Ashok Kumar C.
Clinico-pathological profile of Rickehsial Fever in a rural area of
western Maharashtra, India. Pravara Med Rev. 2013;5(3):5-9.
13. Mahajan SK. Scrub typhus. J.Assoc. of Physic India. 2005;53:954-58.
[PubMed]
How to cite this article?
Sunil S. Vaidya, Atul A. Kulkarni. Clinical study & laborotory
profile of rickettsial fever in children- a study from rural
Maharashtra. Int J Pediatr
Res.2016;3(8):559-562.doi:10.17511/ijpr.2016.8.02.