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| OJHAS Vol. 12, Issue 3:
(Jul-Sep 2013) |
Case Report
Pictorial CME : Spot the Disease
Authors
Pramod Kumar Jaret, Assistant Professor,
Ashok Sharma, Professor,
Balbir Singh Verma, Associate Professor,
Vimal Bharti, Senior Resident,
Department of Medicine, Indira Gandhi Medical College, Shimla (HP), 171001, India.
Address for Correspondence
Dr.Pramod Kumar Jaret,
Assistant Professor,
Department of Medicine,
Indira Gandhi Medical College,
Shimla - 171001, India.
E-mail:
pramodjaret@yahoo.co.in
Citation
Jaret PK, Sharma A, Verma BS, Bharti V. Pictorial CME : Spot the Disease. Online J Health Allied Scs.
2013;12(3):20. Available at URL:
http://www.ojhas.org/issue47/2013-3-20.html
Open Access Archives
http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html
Submitted:Aug 29,
2013; Accepted: Oct 10, 2013; Published: Nov 15, 2013 |
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Case Report:
A 40 year old rural woman visited our outpatient department for the complaints of fever, body aches and painless
sore on face for one week duration. She did not complaint of rash, respiratory difficulty, jaundice or altered sensorium. On examination her
vitals were normal, enlarged tender lymph nodes were palpable in her left pre-auricular area and upper part of neck. Local examination of the face revealed
two oval skin lesions approximately 15mm×8mm located parallel to each other on the left side of the face about 20 mm lateral to margin of left
eye brow. These lesions had indurated, raised , purple-bluish margin and blackish necrotic central crust. She also had mild splenomegaly.
Rest of the systemic examination was unremarkable. Her routine investigations including complete blood counts, random blood sugar, hepatic
and renal function profiles, and chest X-ray were normal.
What investigation would you suggest next and what would be the possible diagnosis?
Answer:
We suspected that the patient was suffering from Scrub typhus as it is an autochthonous infection in
Southeast Asia and it peaks especially during rainy season when farmers have exposure to grassy fields. It is an acute febrile illness that
is caused by an intracellular Gram-negative bacteria Orientia tsutsugamushi[1], and is transmitted from rodents to humans by the larval-stage
trombiculid mites. An infection is heralded by an eschar, which is an inflammatory lesion at the site of the inoculating chigger bite due
to invasion of dermal cells by these microorgansims and resembles skin burn of a cigarette butt.[2] This is followed by the development of a
disseminated papulomacular rash, fever, malaise, myalgia, and anorexia and other complications. In endemic areas, diagnosis is generally made on
clinical grounds alone. Where there is doubt, the diagnosis may be confirmed by a laboratory test such as serology.
So, IgM Elisa for Orientia tsutsugamushi was ordered which turned out to be positive. She was treated with
Capsule Doxycyclin 100 mg b.i.d. and tablet Acetaminophen sos for one week. She was followed up as an outpatient after one week and was found to be cured and not to have developed any complications.
This case was of clinical significant for two reasons viz, it is rare to find the eschar on the face and secondly for
finding multiple eschars. An eschar is usually located in warm, damp areas where pressure from clothing occurs[3] such as perineum,
inguinal region, axilla, underneath the breasts and lower extremities. The largest study on the distribution of eschar on the body of
scrub typhus patients by Kim et al[1] had reported that out of 176 patients, only one patient had multiple eschars.
References:
- Kim DM, Won KJ, Park CY et al. Distribution of eschar on the body of scrub typhus patients. Am J Trop Med Hyg. May 2007;76(5):806-809.
- Mahajan SK. Scrub Typhus: Review Article. JAPI. 2005;53:954-958.
- Aggarwal P, Mahesh DM, Ravi Kumar V, Himral P, Kaushal SS, Verma BS. Atypical Eschar Sites in Scrub Typhus in Sub-Himalayas. JAPI. Feb 2009;57:153.
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