CLINICAL PROFILE OF SCRUB TYPHUS AMONG PAEDIATRIC AGE GROUP IN A TERTIARY CARE CENTER Abstract INTRODUCTION:

INTRODUCTION: Scrub typhus, a dreaded disease in the pre-antibiotic era, was a serious military disease that killed thousands of people in the Far East during WWII. It is a zoonosis that is common throughout Asia and the Pacific Islands. Scrub typhus is a febrile illness characterised by a wide range of symptoms and indications. This disease has a wide spectrum of clinical symptoms, from subclinical through organ failure to death. The objective of this study was to assess the clinical profile of scrub typhus infection among children in a tertiary care hospital in south India.

During the monsoon season (between September and January), the highest number of cases (39;78%) were reported.
Fever was a common occurrence in all scrub cases.Only about a quarter of the youngsters (13;26 percent) had a fever that lasted less than a week when they were admitted to the hospital.The majority of pediatric scrub patients had a fever for more than a week (60%) and a minor group (14%) had a fever for more than two weeks.Other clinical features reported were headache andmyalgia (11% each), cough and runny nose (48%).Thegastrointestinal system was significantly affected inpatients with scrub typhus with symptoms such as vomiting, diarrhea and abdominal pain 26(52%),6(12%) and 16 (32%)respectively.Eschar, a pathognomonic characteristic of scrub typhus, was observed in 32 of the cases (64%).
Eschar was most commonly found in the axilla and groin. Hepatosplenomegaly was another common symptom of scrub typhus. Hepatomegaly was observed in (n=10; 20% of the children) while hepatosplenomegaly was observed in (N=22; 44% of the children). Only (N=6; 12%) of the cases had isolated splenomegaly. Altered sensorium was documented in 7(14%),seizures was observed in 5(10%),Maculopapular rashes were noticed among 9(18%) of patients.
Another common sign of scrub typhus was lymphadenopathy which was observed in (n=24;48 % of the children).In addition, one-quarter of the admitted children had enlarged regional lymph nodes.
In scrub typhus patients, laboratory examination revealed the involvement of all three cell lines. Anaemia, abnormal total leukocyte counts, and thrombocytopenia were found in 33, 17 and 29 of the patients, respectively.
The majority of the patients 32(64%) had mild to moderate anaemia. Only one case of severe anaemia was observed.
The majority of the patients had normal total leukocyte counts. Leukocytosis and leukopenia were found in 13 (26%) and 4 (8%), respectively.
Although thrombocytopenia was a common laboratory finding in paediatric scrub cases, it was only mild to moderate in nearly half of them. Severe thrombocytopenia was only found in two cases.Only 4/14 individuals had elevated SGOT and SGPT, 1/8 had elevated creatinine, and 1/20 had hyponatremia.
Scrub typhus was diagnosed based on a positive serum IgM test. IgM was found positive in all of the patients. Eschar was found in 32 (64 percent) of the 50 individuals studied

DISCUSSION:
Tsutsugamushi fever, commonly known as scrub typhus, is one of the most common causes of acute undifferentiated fever in people of all ages, especially children.Several outbreaks have recently been recorded from across India, particularly during the rainy season (June to December) in south India and the winter season (September to January) in north India. (12,(17)(18)(19)(20)(21) Majority of the cases presented with prolonged fever and non-specific signs and symptoms of acute undifferentiated fever.
However, Acute encephalitis syndrome, multiorgan dysfunction syndrome (MODS) pneumonia, acute respiratory distress syndrome (ARDS), hemophagocyticlymphhistiocytosis, and aortic valve endocarditis were all common serious complications. Although eschar is a pathognomonic sign, it was only found in a limited percentage of cases, making clinical diagnosis difficult . (15,(22)(23)(24)(25)(26)(27) Delay in diagnosis was the primary risk factor for increased morbidity and mortality. (28) In the current study, 72 percent of children attend school and thus are exposed to sick chiggers in the shrubs. However, an unexpected result is the incidence of scrub typhus in under oneyear-old infants who spend most of their time indoors, which is most likely connected to the change in chigger habitat during the monsoon season. (21) In contrast to the previous studies, the incidence of scrub typhus is slightly more in females 27(54%) than males 23(46%).
The incidence of scrub typhus in the state of Tamil Nadu increases during the monsoon season, according to this study (September to January). However, Bhat K et al. identified a rise in the number of scrub typhus cases during the post-monsoon season (between September and November), which coincides with a wet season ideal for the growth of vegetation and the trombiculid mite, comparable to earlier studies done in northern and northeast India. During the monsoon season, chiggers may migrate to a safer environment (within a home), which could explain the greater frequency of scrub typhus in newborns in the current study. (14,17,19) The most common clinical finding in this study was mild to moderate fever. This fever symptom is compatible with the majority of previous studies and literature. (17,29) Seventy-four percent of the participants in the current study had a fever that lasted more than a week.
The counter availability of antibiotics in the locality contributes to the low frequency of prolonged fever for more than two weeks.In contrast to prior studies, maculopapular rashes were found in 18% of cases (20) . The low reporting of rashes in this study is likely due to the study population's dark complexion, which makes rashes more difficult to detect.
Vomiting (n=26;52 %), diarrhoea (n=6;12%), and abdominal pain (n=16;32 %) were all noted, which is consistent with earlier research. According to Narayanasamy et al, the gastrointestinal tract was the most commonly affected system (51%) and the most common symptoms were vomiting (68%) and abdominal pain (42%). (16) Eschar was found in 64% of the current population, mostly in the axilla and groyne. According to previous studies, eschar content ranged from 30 to 67 percent. Eschars were also found on the hairline, umbilicus, gluteal groove, nape of the neck, and behind, among other places. In those instances where there was a high clinical suspicion of scrub typhus, the greater prevalence of eschar in the current study provides direct evidence of good clinical examination and concentrated search for eschar in hidden areas.
In contrast to prior studies that reported predominantly hepatomegaly (13) , this study identified hepatosplenomegaly (n=22; 44%) as a significant finding, with hepatomegaly alone being observed in only (n=10; 20%) instances. Co-infections were found in every case of isolated splenomegaly.
The complications included oedema, respiratory distress, shock, and oliguria in children with coinfections (n=3, 1-malaria, 2-dengue).Furthermore, no deaths were documented in this trial.This excellent treatment of scrub cases without death may be due to the clinician's recognition of scrub typhus cases as a common cause of protracted fever during the monsoon season.
A considerable majority of children (64%) had mild to moderate anaemia, according to laboratory results. This significant anaemia burden must be viewed in the context of underlying nutritional anaemia, which was reported in the NFHS-IV to be 50.4 % among children aged 6 to 59 months in Tamilnadu.
The lack of significance of anaemia as a substantial risk factor in the current study, in contrast to Thomas et alresult's after evaluating 262 children, should be considered in the context of the limited number of patients enrolled. (13) The current study's blood picture differs from the conventional findings in nutritional anaemia, where thrombocytosis is expected. Thrombocytopenia was reported by 58% of the participants in this study.The current study showed a much greater rate of mild thrombocytopenia than prior studies.Co-infection was found in two cases of severe thrombocytopenia. (30,31) Despite the fact that liver enzymes were increased in a few individuals, none of them showed clinical or biochemical signs of jaundice. Only individuals with oliguria or oedema had their renal function tested. In individuals with tachycardia and oedema, the echo was normal. Myocarditis was not found to be present.
ELISA IgM positive was used to diagnose scrub typhus. Scrub typhus is diagnosed in the majority of cases based on clinical suspicion, the presence of eschar, anaemia, thrombocytopenia, and serum IgM positivity. Children less than eight years were given Azithromycin (10 mg/kg/day x 5 days) and those older than eight years were given Doxycycline (5 mg/kg/day x 5 days) according to unit protocol, resulting in complete clinical cure with no recurrence during follow-up.

CONCLUSION:
Scrub typhus is a common cause of acute undifferentiated fever in children and should always be considered as a differential diagnosis, even in babies.The presence of eschar, lymphadenopathy, and capillary leak in febrile children is the hallmark of this disease.
Almost all cases of scrub typhus may be detected with a high index of clinical suspicion, clinical expertise, and serum IgM positivity. Scrub typhus should be recognised as a differential in any undifferentiated febrile illness obtained in the community, regardless of the appearance of an eschar, and requires empirical therapy as well as scrub typhus tests.