Case Report
Bilateral Symmetrical Brachial Plexopathy in Association with Scrub Typhus: A Rare Presentation
Authors
Manish Mittal, Associate Professor of Neurology,
Garima Mittal, Associate Professor
of Microbiology,
Deepak Goel, Professor of Neurology,
Yashpal Singh, Professor
of Neurology,
Himalayan Institute of Medical Sciences, SRHU Jolly Grant, Dehradun, India.
Address for Correspondence
Garima Mittal,
Associate Professor,
Microbiology Department,
Himalayan Institute of Medical Sciences,
Jolly Grant, Dehradun-248140,
India.
E-mail:
garimamittal80@gmail.com
Citation
Mittal M, Mittal G, Goel D, Singh Y. Bilateral Symmetrical Brachial Plexopathy in Association with Scrub Typhus: A Rare Presentation. Online J Health Allied Scs.
2015;14(3):14. Available at URL:
http://www.ojhas.org/issue55/2015-3-14.html
Open Access Archives
http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Sep 25,
2015; Accepted: Sep 30, 2015; Published: Oct 15, 2015 |
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Introduction:
Scrub typhus is rampant in northern, eastern and southern India. Apart from these regions, recently it has also been reported from central India.(1) Humans are infected accidentally and the case fatality can be significantly high if the disease is not identified in time. So, it is imperative to differentiate scrub typhus from other febrile illnesses and to start specific treatment at the earliest to decrease morbidity and mortality. This disease can develop neurological complications like meningoencephalitis, brachial plexopathy, Guillain barre syndromeetc. Herein, we report a rare case of bilateral brachial plexopathy associated with scrub typhus infection.
Case Report
A 50 year old male, chronic smoker was admitted to Neurology department with complaints of weakness in both the arms such that he could not lift his arms above shoulder, could not hold weight with his arms and could not write. He also complained of pain in both the arms which increased on walking when upper limbs were not supported.
Patient gave history of fever 2 months back. Fever was accompanied with generalized bodyaches. On thorough investigations, blood culture showed no growth, malaria rapid test and dengue serology was negative. Scrub typhus IgM ELISA was positive. Hence diagnosis of scrub typhus was made and patient was treated with antibiotics like doxycycline and azithromycin. Patient was discharged from hospital in satisfactory condition.
Then after two months, the patient presented with complaints of pain and weakness in both upper limbs. On examination patient was conscious and oriented. Vital signs were normal. Central nervous system examination showed that power in shoulder muscles (flexor, extensor and abductor) were 0/5 whereas in elbow flexion and extension it was 3/5. Sensations were normal and nothing abnormal was detected on other system examination.
On investigations, electromyography (EMG) showed large, polyphasic MVAP in biceps with incomplete recruitment suggestive of neurogenic potentials. NCV was also suggestive of upper brachial plexopathy. CSF analysis was normal. Viral markers were non-reactive. MRI cervical spine showed normal findings. Hence diagnosis of bilateral, symmetrical brachial plexopathy, post scrub typhus was made.
Patient was initiated on electrical muscle stimulation, physiotherapy along with supportive and symptomatic treatment and discharged with satisfactory condition.
Discussion:
Scrub typhus is an acute febrile illness caused by rickettsiae, Orientia tsutsugamushi. The disease is transmitted to humans through the bite of an infected chigger, the larval stage of trombiculid mite. (2)
The first report from this area was in 2010, when nine adult cases of scrub typhus were reported. (3) The reasons for emergence of scrub typhus in this part of India are not clear. The Garhwal region is hilly with a climate conducive for the breeding of the vector. The large scale deforestation along with ongoing infra-structural, industrial and river development projects may be facilitating human contact with and bites by infected chiggers thereby promoting disease acquisition.
Our patient who initially presented with fever and bodyaches, later on developed bilateral bracial plexopathy due to scrub typhus. Similar case has been reported by Singh SK et al where they reported unilateral brachial neuritis and eschar was noted in scapular region.(4) Another isolated case report of brachial plexus neuropathy with scrub typhus who improved on treatment also finds a place in literature .(5)Other important neurological complication of scrub typhus is meningoencephalitis which has been described by Gulati S et al. They have mentioned that seizures, delirium, cerebellitis, myelitis, cerebral hemorrhage, and hearing loss are the other neurological presentations of this infectious disease.(6) A patient of scrub typhus with pain indistinguishable from trigeminal neuralgia was reported, who improved clinically after treatment.(7) Another report mentions development of bilateral simultaneous facial nerve palsy in convalescent period, which improved on administration of steroids.(8)
Recognizing the full spectrum of clinical manifestations can help clinicians in considering appropriate differential diagnosis amongst the dengue fever like illnesses. Entomological studies are needed to study the density of the vector and to institute vector control measures in order to prevent this relatively benign, yet potentially fatal, clinical entity from spiralling into a major public health issue
To the best of our knowledge, this is the first case reported to have bilateral brachial plexopathy after scrub typhus infection. Though literature search mentions case reports with unilateral brachial neuritis post scrub typhus.
Conclusion:
To conclude, scrub typhus may present with a wide spectrum of neurological manifestations. Knowledge of these manifestations will enable clinicians to consider scrub typhus as one of the differential diagnosis of acute febrile illnesses with neurological involvement. Timely recognition of these complications is of paramount importance to ensure a favorable outcome.
References
- Rathi NB, Rathi AN, Goodman MH, et al. Rickettsial diseases in Central India: Proposed clinical scoring system for early detection of spotted fever.
Indian Pediatr. 2011;48:867–72.
- Reller ME, Dumler JS. Scrub Typhus (Orientia tsutsugamushi). In:Kleigman RM et al: Nelson Textbook of Pediatrics. Philadelphia: Elsevier:19th ed. 2011. pp 1045-6.
- Ahmad S, Srivastava S, Verma SK, et al. Scrub typhus in Uttarakhand, India: a common rickettsial disease in an uncommon geographical region.
Trop Doct 2010;40(3):188-190.
- Singh SS, Vidyasagar S. Brachial Neuritis in Association with Scrub Typhus: A Rare Presentation.
Int J Science Research. 2015;4(1):2629-2630.
- Ting KS, Lin JC, Chang MK. Brachial plexus neuropathy associated with scrub typhus: Report of a case.
J Formos Med Assoc. 1992;91:110–2.
- Gulati S, Maheshwari A. Neurological manifestations of scrub typhus. Ann Indian Acad Neurol.
2013 Jan-Mar;16(1):131
- Arai M, Nakamura A, Shichi D. Case of tsutsugamushi disease (scrub typhus) presenting with fever and pain indistinguishable from trigeminal neuralgia.
Rinsho Shinkeigaku. 2007;47:362-4
- Lin WR, Chen TC, Lin CY, et al. Bilateral simultaneous facial palsy following scrub typhus meningitis: A case report and literature review.
Kaohsiung J Med Sci. 2011;27:573–6.
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