Gastrointestinal Symptoms of Scrub Typhusseptic Patients

Scrub typhus is an acute febrile illness caused by Orientia induced vasculitis, which is common in Asia and the Pacific Islands and is sometimes also encountered in Western countries. Even though it can cause multi-organ dysfunctions, there is limited information regarding the relationship between scrub typhus infection and gastrointestinal dysfunction. Therefore, a cross-sectional study was conducted to discover the gastrointestinal manifestations of septic patients with scrub typhus infection. During the study period, 80 septic cases were recruited, and according to the results of immunofluorescent antibody testing (IFA), 20 (25%) were found to have scrub typhus infection. The most common gastrointestinal symptoms of scrub typhus patients were vomiting 13 (65%), nausea 12 (60%), diarrhea 9 (45%), and hametamesis or melena 5 (25%). Gastrointestinal signs included hepatomegaly 8 (40%), jaundice 7 (35%), and abdominal pain 4 (20%). Elevation of SGOT, SGPT, and alkaline phosphatase were 16 (80%), 14 (70%), and 16 (80%), respectively. Direct bilirubin was elevated in 19 (95%) of the cases and half of the cases had a low serum protein level. Of scrub typhus cases, 8 (40%) had eschars. The sites of eschars were mostly in hidden areas, such as on the back, genitalia and abdomen. Three of the five patients with eschar had hepatomegaly on ultrasound examination. The significant findings of the scrub typhus septic patients with eschar on endoscopic examination were gastritis in two cases, gastritis with gastric erosion in two cases, and one case showed a duodenal ulcer and erosion. The differentiating point for endoscopic findings in scrub typhus compared to the other causes was that the stomach lesions were more frequent and severe than the duodenal lesions. According to our endoscopic findings, physicians should be aware of gastric and duodenal lesions in febrile patients with gastrointestinal symptoms, such as abdominal pain or discomfort and indigestion. Scrub typhus can cause gastrointestinal and liver dysfunction. scrub typhus still occur each year, and it is an important cause of febrile illness in endemic areas. The disease is transmitted in an extremely large geographic area ranging from the Indian subcontinent to Japan, the Philippines, Indonesia, New Guinea, Sri Lanka, and the Islands of the Chagos Archipelago (Watt and Olson, 2000). The incidence figures for scrub typhus are generally unavailable because adequate surveillance systems are lacking. According to a report by Silpapojakul (1997), the sero-prevalence rates in Korea, India, Nepal, Indonesia, the Philippines and Malaysia were 20, 2, 12, 1-16, 3-11 and 669%, respectively. In Thailand, it occurs in 10% of cases of fever of unknown origin (MOPH, Thailand, 1993-2001). Scrub typhus infection is a serious public health problem in the Southeast Pacific SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH 846 Vol 35 No. 4 December 2004 and Southeast Asia. (Ralph and Jeronae, 1987; Berman et al, 1973; Berman and Kundin, 1973; Joseph and Daniel, 1992; Singharaj and Watt, 1997). Scrub typhus can be severe with complications, which have been reported in Taiwan to include pneumonitis 36% (3/33), adult respiratory distress syndrome (ARDS) 15% (5/33), acute renal failure 9% (3/33), myocarditis 3% (1/33), and septic shock 3% (1/33) (Tsay and Chang, 1998). Sepsis may be complicated by infections with bacteria, viruses, rickettsiae, mycobacteria, fungi, and parasites (McGowen et al, 1975). Sepsis is also associated with upper gastrointestinal tract bleeding and hepatocellular dysfunction and causes an elevation in liver transaminases (Altemeier and Fullen, 1972). Studies have shown that complications usually develop after the first week of illness; these included pneumonitis, meningoencephalitis, renal failure, and jaundice. (Silpapojakul, 1997). One study in a Taipei hospital revealed that hepatic dysfunction occur in 77% (36/47) of patients. In liver function testing, the percentage of abnormalities were 74.5% for aspartate aminontransferase, 74.5% for alanine aminontransferase, 57.4% for alkaline phosphatase, and 44.7% for serum bilirubin. Six patients presented with a picture of true hepatitis, similar to acute viral hepatitis, indicating that hepatocellular damage does occur in scrub typhus infection. Endoscopic findings in scrub typhus patients in Korea revealed superficial gastritis (70%), petechiae (37%), purpura (34.5%), hemorrhage (29.3%), erosion (32.7%), and ulcers with bleeding (10.3%) (Kim el al, 2000). Scrub typhus can present with multiorgan involvement, pulmonary complications are common, so most studies have focused on this. The relationship between gastrointestinal dysfunction and scrub typhus has had little attention. The current study was conducted in order to discover the gastrointestinal manifestations of septic patients with scrub typhus and to compare these manifestations with those in non-scrub typhus patients. The results of present study can provide a baseline of information regarding gastrointestinal dysfunction in scrub typhus, to help physicians with their proper management. MATERIAL AND METHODS Study area and population The study was conducted from 12 November 2002 to 4 January 2003 in Maharat Hospital Nakhon Ratchasima Province. It is a tertiary hospital, located in the northeastern part of the country. This area is endemic for scrub typhus (MOPH, Thailand, 1993-2001). We conducted the study, in this hospital’s medical wards and ICU for 7 weeks, among 80 septic patients. The inclusion criteria for study subjects were: all patients, both male and female, who were admitted to the medical wards or ICU unit at Maharat Hospital during the study period, age ≥14 years, and septic, by clinical evidence and who met two or more of the following conditions: T >38oC or T< 36oC, tachypnea (RR > 20 breaths/minute), tachycardia (HR >90 beats/ minute), PaCO2 <32 mmHg (<4.3 Kpa), white blood cell count >12,000 cells/mm or <4,000 cells/ mm or 10% immature forms. Pregnant women and patients who stayed in hospital <24 hours were not included in this study.