WFSICCM SEOUL Managing Scrub Typhus in ICU

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1 WFSICCM SEOUL 2015 Managing Scrub Typhus in ICU Dr. Shivakumar Iyer Professor & Head Dept of Critical Care Medicine Bharati Vidyapeeth University Medical College, Pune President Indian Society of Critical Care Medicine

2 JOURNAL OF THE ASSOCIATION OF PHYSICIANS OF INDIA JANUARY 2014 VOL. 62

3 Managing Scrub Typhus in ICU History Epidemiology Pathophysiology Pathology Clinical features ICU presentation Diagnosis Management Orientia Tsutsugamushi infection: overview and immune responses Seung-Yong Seong et al Microbes and Infection 2001

4 Introduction Zoonotic rickettsial illness Orientia tsutsugamushi Tsutsuga illness mushi insect Scrub = scrubby vegetation typhus = fever

5 Tsutsugamushi triangle Far eastern Russia Northern Japan Pakistan (west) overview and immune responses and Infection 2001 Northern Australia (south) South-East Asia including India, Bangladesh, China, Taiwan, South Korea, Japan and Northern Australia

6 History First described from Japan in 1899 Severe epidemics of the disease occurred among troops in Burma and Ceylon in WWII Several members of the U.S. Army's 5307th Composite Unit Merrill s Marauders died New Guinea WWII US troops stationed in Japan after WWII No antibiotics or vaccine was available

7 Etiology: O tsutsugamushi Three major serotypes - Karp, Gilliam & Kato Vector: chiggers (larva of trombiculid mite) Reservoir: chiggers & rats Transovarian transmission Normal cycle: rat to mite to rat Humans are accidentally infected

8 Pathogenesis, Pathophysiology, Pathology Bite by chigger Incoculation of Orientia tsutsugamushi Local eschar with regional lymphadenopathy Rickettsemia Disseminated vasculitis DIC Vascular leak Pulm edema Hepatic inv Neurologic inv Myocarditis

9 Clinical Features Incubation period: 1 to 3 weeks Sudden onset of fever, headache & myalgia Delirium, nausea, vomiting, cough, jaundice Maculopapular rash Begins on trunk and spreads to extremities (centrifugal spread) Eschar

10 Eschar

11 Sites of Eschar Kundavaram A P, Jonathan A J, Nathaniel S D, Varghese G M. Eschar in scrub typhus: A valuable clue to the diagnosis. J Postgrad Med 2013;59:177-8

12 Clinical Course

13 Complications ARDS / Pneumonitis Myocarditis Shock Neurologic complications Hepatitis DIC Thrombocytopenia Hemophagocytic syndrome AKI Acute pancreatitis Transient adrenal insufficiency Thyroiditis Occasionally acute abdomen JV Peter et al World J Crit Care Med 2015 August 4; 4(3):

14 When should scrub typhus be suspected? Undifferentiated febrile illness with: Pathognomonic eschar Evidence of multisystem involvement, especially with: - Transaminase elevation - Thrombocytopenia - Leukocytosis

15 Lab Diagnosis Serology Weil-Felix Indirect immunofluorescence antibody (IFA) Indirect immunoperoxidase (IIP) ELISA for IgG & IgM antibodies (recombinant 56 kd antigen): sensitivity & specificity >90% Rapid diagnostic tests lateral flow immunochromatographic test (ICT) Immuno- blot test Latex agglutination test PCR Culture Immunohistochemistry

16 Lab Diagnosis

17 ICU presentation & Organ dysfunction

20 Outcome

21 Univariate Analysis

22 Multivariate analysis

23 ICU presentation & Organ dysfunction 116 patients (APACHE) II score was 19.6 ± patients had >= 3 organ dysfunction 16 patients (15%) had all 6 organs dysfunction Respiratory dysfunction (96.6%) Ventilatory support required in 87.9%. Cardiovascular dysfunction 61.7% Renal & Hepatic dysfunction i63.8% Thirteen patients (11.2%) were dialyzed

24 Treatment Penicillins, cephalosporins, carbapenems aminoglycosides don t work!!! Resistance to quinolones has been reported!!! Severe scrub typhus infection: Clinical features, diagnostic challenges and management John Victor Peter, Thomas I Sudarsan, John Anthony J Prakash, George M Varghese World J Crit Care Med 2015 August 4; 4(3):

25 Treatment Organ support Mechanical ventilation NIV may be tried in milder cases Fluids and vasopressor support Renal replacement therapy Platelet transfusions, other blood products

26 Mortality 116 patient ICU cohort (Griffith GM et al 2014) Mortality was 24.1% APACHE- II score and duration of fever were independently associated with mortality. 261 patients from Taiwan (Su TH et al 2013) no mortality was observed 623 patients from South India ( Varghese GM et al) scrub typhus mild to critically ill mortality was 9% Decreasing trend over 4 years

27 Summary Scrub typhus is a not an uncommon cause of Acute Febrile Illness & MODS in ICU Diagnosis may be missed if eschar is not sought & typical epidemiology is missed Lab confirmation is with IgM ELISA or IFA or IIP Severe scrub typhus in ICU has significant mortality Early recognition & treatment with Doxy can significantly reduce mortality

28 Thank You... the secret of the care of the patient is in caring for the patient. Francis Weld Peabody

- Mycoplasma and Ureaplasma. - Rickettsia

- Mycoplasma and Ureaplasma. - Rickettsia - Mycoplasma and Ureaplasma - Rickettsia Mycoplasma and Ureaplasma Family: Mycoplasmataceae Genus: Mycoplasma Species: M. pneumoniae Species: M. hominis Species: M. genitalium Genus: Ureaplasma Species: