Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation

Ahmad Ozair
Ahmad OzairIntern Physician en King George's Medical University, Lucknow, India

We here present a case of scrub typhus (ST) manifesting with hemiparesis, which, to the best of our knowledge, has been reported few times prior. ST typically presents with headache, fever, cough, dyspnoea, and/or gastrointestinal symptoms. Early treatment ensures swift improvement. However, this common cause of febrile illness is often overlooked, even in endemic regions. This is due to a nonspecific presentation, low index of suspicion, and lack of diagnostic facilities. Even our institution, an apex public referral center of northern India, lacked affordable testing a decade ago. After testing began, a significant number of cases, which would have previously been labeled as “fever of unknown origin,” were found to be of ST and confirmed by response to doxycycline.

Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation
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Con icts of interest
There are no con icts of interest.
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(a‑c) Restricted diffusion on the right‑sided temporo‑parieto‑occipital
cortex on diffusion‑weighted imaging, suggestive of encephalitis (arrows).
(d and e) Leptomeningeal enhancement on an axial section of contrast‑enhanced
brain MRI, suggestive of meningitis (arrows)
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Syed F Abbas, Ahmad Ozair, Vivek Kumar,
D Himanshu
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Scrub Typhus Presenting with Hemiparesis: Case Report of a Rare Manifestation

  • 2. 1HXURORJ ,QGLD 1HXURORJLFDO 6RFLHW RI ,QGLD _ 3XEOLVKHG E :ROWHUV .OXZHU 0HGNQRZ 5KT 9G JGTG RTGUGPV C ECUG QH UETWD V[RJWU 56 OCPKHGUVKPI KVJ JGOKRCTGUKU JKEJ VQ VJG DGUV QH QWT MPQ NGFIG JCU DGGP TGRQTVGF HG VKOGU RTKQT = ? 56 V[RKECNN[ RTGUGPVU KVJ headache, fever, cough, dyspnoea, and/or gastrointestinal U[ORVQOU = ? 'CTN[ VTGCVOGPV GPUWTGU U KHV KORTQXGOGPV *Q GXGT VJKU EQOOQP ECWUG QH HGDTKNG KNNPGUU KU QHVGP QXGTNQQMGF GXGP KP GPFGOKE TGIKQPU 6JKU KU FWG VQ C nonspeci c presentation, low index of suspicion, and lack of FKCIPQUVKE HCEKNKVKGU = ? 'XGP QWT KPUVKVWVKQP CP CRGZ RWDNKE TGHGTTCN EGPVGT QH PQTVJGTP +PFKC NCEMGF CHHQTFCDNG VGUVKPI a decade ago. After testing began, a signi cant number of ECUGU JKEJ QWNF JCXG RTGXKQWUN[ DGGP NCDGNGF CU HGXGT of unknown origin,” were found to be of ST and con rmed D[ TGURQPUG VQ FQZ[E[ENKPG [GCT QNF OCNG RTGUGPVGF KVJ CEWVG QPUGV CNVGTGF UGPUQTKWO CPF NGHV UKFGF JGOKRCTGUKU KVJ C GGM U JKUVQT[ QH HGXGT RTQFWEVKXG EQWIJ CPF DTGCVJNGUUPGUU 9JKNG JGOQF[PCOKECNN[ UVCDNG JG JCF DKNCVGTCN ETGRKVCVKQPU KVJ )NCUIQ %QOC 5ECNG QH ' 8 . There were bilateral exor plantar responses, normal re exes, absent neck rigidity, CPF PQ QVJGT PGWTQNQIKECN FGHKEKVU 1VJGT U[UVGOU GTG WPTGOCTMCDNG +PKVKCNKPXGUVKICVKQPU TGXGCNGF NGWMQE[VQUKU VJTQODQE[VQRGPKC UVCIG CEWVG MKFPG[ KPLWT[ TCKUGF UGTWO VTCPUCOKPCUGU CPF CNMCNKPG RJQURJCVCUG 0Q FGTCPIGOGPVU GTG RTGUGPV KP UGTWO GNGEVTQN[VGU DKNKTWDKP CNDWOKP CPF INWEQUG Cerebrospinal uid (CSF) had protein 110 mg/dL, normal INWEQUG EQTTGURQPFKPI VQ RNCUOC INWEQUG NGWEQE[VG EQWPV 30/mm KVJ RNGQE[VQUKU CPF CFGPQUKPG FGCOKPCUG & 14.2 IU/L, raising suspicion of tubercular meningitis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without functional de cits. 6JKU KU QPG QH VJG TCTG TGRQTVGF ECUGU KP NKVGTCVWTG QH 56 RTGUGPVKPI KVJ JGOKRCTGUKU JKEJ CU UGEQPFCT[ VQ GKVJGT UVTQMG = ? 9G JCXG CNUQ UGGP 56 RCTCFQZKECNN[ RTGUGPV CU KUQNCVGF NCVGTCN TGEVWU RCNU[ CPF KPVTCEGTGDTCN JGOQTTJCIG = ? GECWUG ST can manifest with multiorgan dysfunction and/or death in ECUGU QH VJGTCRGWVKE FGNC[ GCTN[ FKCIPQUKU KU ETKVKECN = ? 56 KPFWEGF OGPKPIKVKU QT OGPKPIQGPEGRJCNKVKU KU TGRQTVGF KP QH ECUGU KVJ FKHHGTGPVKCN FKCIPQUGU DGKPI VWDGTEWNCT OGPKPIKVKU CPF EGTGDTCN OCNCTKC = ? %5( CPCN[UKU GURGEKCNN[ & NGXGNU CPF CPVK 56 +I VGUVKPI KU ETWEKCNKP C PCVKQP JGTG CDQXG GVKQNQIKGU CTG GPFGOKE = ? 6Q EQPENWFG UGTQNQIKECN VGUVKPI HQT 56 WTIGPVN[ PGGFU VQ DG OCFG KFGN[ CXCKNCDNG RCP +PFKC = ? ( PCPE CN WRRQTV CPF RQP QT J R 0KN Con icts of interest There are no con icts of interest. 4GHGTGPEG &KHQ 3+ +XQJ .+ &KHQJ 6‑ +VX .1 6FUXE W SKXV DVVRFLDWHG DFXWH GLVVHPLQDWHG HQFHSKDORP HOLWLV FWD 1HXURO 7DLZDQ 0DKDMDQ 6. 6FUXE W SKXV ‑ VVRF 3K VLFLDQV ,QGLD 0DKDMDQ 6. 0DKDMDQ6. 1HXURSV FKLDWULF PDQLIHVWDWLRQV RI VFUXE W SKXV ‑ 1HXURVFL 5XUDO 3UDFW 5DKL 0 XSWH 0' KDUJDYD 9DUJKHVH 0 URUD 5 '+5 ,&05 XLGHOLQHV IRU GLDJQRVLV DQG PDQDJHPHQW RI ULFNHWWVLDO HWWHU WR GLWRU 6FUXE 7 SKXV 3UHVHQWLQJ LWK HPLSDUHVLV DVH 5HSRUW RI D 5DUH DQLIHVWDWLRQ (a‑c) Restricted diffusion on the right‑sided temporo‑parieto‑occipital cortex on diffusion‑weighted imaging, suggestive of encephalitis (arrows). (d and e) Leptomeningeal enhancement on an axial section of contrast‑enhanced brain MRI, suggestive of meningitis (arrows) G F E D H
  • 3. 1HXURORJ ,QGLD _ 9ROXPH _ ,VVXH _ -XO XJXVW L GLVHDVHV LQ ,QGLD ,QGLDQ ‑ 0HG 5HV 2]DLU .XPDU 9 +LPDQVKX ' KDW 9 UDUH HWLRORJ EHKLQG LVRODWHG ODWHUDO UHFWXV SDOV 6FUXE W SKXV ‑ )DPLO 0HG 3ULP &DUH .RWZDO 0 9DLVK ( XSWD .. 2]DLU 6FUXE W SKXV PDQLIHVWLQJ ZLWK LQWUDFHUHEUDO KHPRUUKDJH &DVH UHSRUW DQG UHYLHZ RI OLWHUDWXUH ‑ )DPLO 0HG 3ULP &DUH Syed F Abbas, Ahmad Ozair, Vivek Kumar, D Himanshu 'HSDUWPHQW RI 0HGLFLQH .LQJ *HRUJH V 0HGLFDO 8QLYHUVLW XFNQRZ 8WWDU 3UDGHVK ,QGLD Address for correspondence: 'U KPDG 2 DLU )DFXOW RI 0HGLFLQH .LQJ HRUJH V 0HGLFDO 8QLYHUVLW /XFNQRZ 8WWDU 3UDGHVK ,QGLD ( PDLO DKPDGR DLU NJPFLQGLD HGX VV V RQ Q Website: ZZZ QHXURORJ LQGLD FRP V RQV R 2, How to cite this article: EEDV 6) 2 DLU .XPDU 9 LPDQVKX ' 6FUXE 7 SKXV 3UHVHQWLQJ ZLWK HPLSDUHVLV DVH 5HSRUW RI D 5DUH 0DQLIHVWDWLRQ 1HXURO ,QGLD Submitted: 6HS Revised: -XO Accepted: 6HS Published: 6HS 1HXURORJ ,QGLD 1HXURORJLFDO 6RFLHW RI ,QGLD _ 3XEOLVKHG E :ROWHUV .OXZHU 0HGNQRZ This isan openaccess journal, and ar cles are distributedunderthe terms ofthe Crea ve Commons A ribu on‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new crea ons are licensed under the iden cal terms.