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| OJHAS Vol. 14, Issue 2:
(April-June 2015) |
Case Report
Rare Causal Association of Scrub Typhus and Fulminant Hepatic Failure.
Authors
Yuthika Malhotra, Department of General Medicine,
Sohaib Ahmad, Department of General Medicine,
Minakshi Dhar, Department of General Medicine,
Garima Mittal, Department of Microbiology,
Nowneet Kumar Bhat, Department of Pediatrics,
Nadia Shirazi, Department of Pathology,
Swami Rama Himalayan University, Dehradun.
Address for Correspondence
Dr. Sohaib Ahmad,
Associate Professor,
Department of Medicine,
HIMS, SRH University,
Swami Rama Nagar, Dehradun-248140
Uttarakhand, India.
E-mail:
sohadia@hotmail.com
Citation
Malhotra Y, Ahmad S, Dhar M, Mittal G, Bhat NK, Shirazi N. Rare Causal Association of Scrub Typhus and Fulminant Hepatic Failure. Online J Health Allied Scs.
2015;14(2):7. Available at URL:
http://www.ojhas.org/issue54/2015-2-7.html
Open Access Archives
http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Jan 30,
2015; Accepted: Jun 20, 2015; Published: July 15, 2015 |
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Abstract: We report fulminant hepatic failure, an extremely rare manifestation of scrub typhus, in a young male who presented with a brief history of fever, jaundice and altered sensorium.
Key Words:
Scrub typhus, Jaundice, Fulminant hepatic failure |
Case Report
A 34 years old male presented to the emergency with fever for 7 days, jaundice for 4 days and altered sensorium for 1 day. Patient was a social drinker and smoker (7.5 pack years). On examination, patient was in grade IV encephalopathy, had marked icterus and hepato-splenomegaly. There was no rash, lymphadenopathy or eschar.
A provisional differential diagnosis of malaria and viral hepatitis was kept and investigations were conducted (Table 1). Rapid card test and peripheral blood smear was negative for malaria and serology was negative for hepatotrophic viruses A, B and E. Further investigations revealed positive scrub typhus serology (both rapid and IgM ELISA). Blood culture was sterile and lumbar puncture was deferred in view of normal imaging and positive scrub serology. Patient also had deranged prothrombin time but a normal gastro-duodenoscopy. A diagnosis of acute hepatic failure due to scrub typhus infection was made and supportive and symptomatic treatment was administered along with doxycycline.
Table 1: Investigation profile of the patient |
| Biochemical Tests |
Day 1 |
Day 2 |
Day 3 |
ALT (IU/L) |
3033 |
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1761 |
AST (IU/L) |
1572 |
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746 |
ALP (IU/L) |
205 |
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Total protein (g/dL) |
5.8 |
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Albumin (g/dL) |
2.5 |
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Globulin (g/dL) |
3.3 |
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Direst Bilirubin (mg/dL) |
17.38 |
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Indirect Bilirubin (mg/dL) |
17.42 |
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Total Bilirubin (mg/dL) |
34.8 |
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A/G ratio |
0.76 |
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Prothrombin time |
> 1 min |
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INR |
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4.5 |
2.1 |
Creatinine (mg/dL) |
0.92 |
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Potassium (mmol/L) |
4.21 |
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Sodium (mmol/L) |
134.93 |
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BUN (mg/dL) |
2.3 |
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Serum ammonia (mcg/dL) |
60 |
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The patient started showing improvement in his sensorium and the coagulation profile after 72 hours of treatment. However, due to the attendants’ request, he was transferred to another centre with transplant facility. A follow-up communication with the centre revealed that he improved on the same conservative treatment and was discharged after 5 days.
Discussion
The case highlights the potential of Orientia tsutsugamushi of causing acute hepatic failure. Studies on patients with scrub typhus have reported elevation of liver transaminases in up to 90% patients[1], mostly mild to moderate. Scrub hepatitis with high liver transaminases (>5 fold elevation) has rarely been described in the literature. Fever and jaundice are commonly seen in acute malaria while benign elevation of liver transaminases without/ with mild icterus and fever has also been reported in dengue fever, the two main differential diagnosis of scrub typhus. Encephalopathy can also be seen in malaria while it occurs unusually in dengue.
In a study by Deepak et al, in India, 2 patients with scrub typhus infection manifested as acute hepatic failure.[2] Submassive hepatocellular necrosis, inflammatory cell infiltration in Glisson’s capsules, and sporadic fibrin thrombi in the hepatic sinusoids were demonstrated in a similar but fatal case related to disseminated intravascular coagulation.[3] Whether the cause of hepatitis in all cases is because of a direct effect of the organism, an immune-mediated response or vasculitis is not known. The myriad of complications of and recognition of acute hepatic failure in scrub typhus merits diagnostic evaluation in patients with fulminant hepatic failure after ruling out acute malaria and viral hepatitis. Scrub typhus is likely in patients from an endemic area presenting with fever, varying degrees of hepatic dysfunction, even acute hepatitis, especially if skin lesions including eschar and maculopapular rash exist.
The limitation in this case was the non-availability of PCR for confirmation of O. tsutsugamushi. However, the exclusion of other common viral etiologies and absence of history of toxin exposure offsets this limitation to a certain extent. In conclusion, the case highlights scrub typhus as a potential cause of acute liver failure in the absence of or non-resolving cases of acute malaria, acute viral hepatitis and exposure to toxins.
References
- Hu ML, Liu JW, Wu KL et al. Short report: abnormal liver function in scrub typhus. Am J Trop Med Hyg 2005;73:667-8.
- Deepak NA, Patel ND. Differential diagnosis of acute liver failure in India. Ann Hepatol 2006;5:150-6.
- Shioi Y, Murakami A, Takikawa Y et al. Autopsy case of acute liver failure due to scrub typhus. Clin J Gastroenterology 2009;2(4):310-4.
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