CLINICAL PROFILE OF RICKETTSIAL FEVER An alarming epidemic in children
Dr. S S Vaidya*, Dr Atul Kulkarni**, Dr U R Warerkar***, Dr.Anwar Patel, (Resident) ****
Dept. of Pediatrics, Ashwini Hospital, Solapur. *, Dept. of Pediatrics, Ashwini Hospital, Solapur. **, Dept. of Pediatrics, Ashwini Hospital, Solapur. ***, Dept. of Pediatrics, Ashwini Hospital, Solapur.****
Introduction:Rickettsial fever is an acute febrile zoonotic disease spread by bites of ticks and mites. Rickettsiae make up a family of Gram -ve coccobaccilli and short bacilli that grow strictly in eukaryotic cells. They are obligate intracellular parasites. Humans are accidental host. The family rickettsiae is named after Howard Taylor Ricketts who discovered spotted fever and died during his studies (1909). The family has been classified in 4 genera:
  • Rickettsia
  • Coxiella
  • Rochemalia
  • Ehrlichia

Rickettsia have varied clinical spectrum of manifestations, including the CNS, RS, and GIT. Illness may be inapparent or in severe lethal form.

Prevalence of this disease is worldwide and in recent times increased incidence in India. The varied clinical spectrum, lack of clinical suspicion, absence of adequate laboratory techniques, expensive tests, all these pose a great challenge in diagnosis and treatment.

Rickettsial disease can be dangerous, if missed. We have noticed increased incidence in the past 4 years. Thus we conducted a study, to evaluate the clinical data of patients suffering from it and admitted to our hospital. This study aims to increase clinical suspicion, awareness about laboratory evaluations and treatment of rickettsial infections.

Type of study: Retrospective study

Methodology: This study was conducted from the patients admitted in our hospital, Ashwini Sahkari Rugnalaya, Solapur, from the month of Jan '06 to Sept '06.
The Inclusion Criteria were
  • Clinical suspicion
  • Supportive lab evidence - Weil Felix positive leucocytosis, thrombocytopenia,
  • Clinical Suspicion was based on history of fever, non-confluent maculopapular or purpuric rash involving palms and soles, and neurological symptoms.
  • Weil Felix test for (OX-19, 0X-2, 0X-K strains) was done on each patient of clinical suspicion. It is a slide agglutination test done according to manufacturer's instructions, from Plasmatech laboratories, Bridfort, UK. The kit tests serum dilutions from 1:20 to 1:320. Significant titre is 1:80, those with positive titre were included in our study.

    On admission, data of age, sex, local residing area, exposure to animals, etc was recorded and, complete blood count, malarial parasite, urine examination was done on all patients.

    CSF, electrolytes, chest -X-ray, USG, dengue IgM, CT scan done as and when needed.

    All patients were treated with:
    • chloramphenicol (100 mg/kg/day) in 3 divided doses or
    • doxycycline (5 mg/kg/day) as single dose or
    • in some cases both drugs were given

Observations: In our study of 9 months, 43 patients satisfied our inclusion criteria, age ranged from 6 months to 12 years, maximum incidence in 2 to 7 years age group (70%), male to female ratio was 1.2:1.
Major Presenting Symptoms

Fever (100%),
Hepatosplenomegaly (56%),
GI upset (25%),
Pneumonia 4%
Rash (85%),
Altered sensorium (54%),
Joint pain (12.5%),
Edema (60%),
Convulsions (34 %),
Upper GI bleed in 7%,


Mean Hb was 9.3 gm/dl; Leucocytosis (>10,000 cells/mm) in 66%, thrombocytopenia (<1 lakh) 56%.

CSF analysis done in 25 patients of which 10 were abnormal, sugar low in 6 cases, proteins high in 8 cases, pleocytosis in all cases with mean cell count 78 cells/mm.

CT scan was done in 18 patients, of which 8 were normal, 7 had cerebral edema, and 3 with features of meningitis. 5 children required mechanical ventilation, out of it 3 expired and 2 recovered well. Responses to doxy, chloramphenicol was quite good and most were afebrile by 48-72 hours. Out of total 43 cases, 37 (92%) recovered well, 7% expired and 3 cases went AMA.
Discussion
Rickettsial diseases are an important but often under-recognized cause of febrile illness locally. Of the wide range of rickettsial diseases, Typhus disease is the most commonly recognized entity in our area.

In our study, the M:F ratio was 1.2:1, while study at Singapore had M:F of 2.3:1. Majority of patients presented with fever and rash, while in Singapore they had fever and headache, rash only in 56%. Hepatosplenomegaly we had in 56%, more in comparison to S K Mahajan et al. We had altered sensorium, convulsions, almost double that of S K Mahajan (24%, 18%)

In our study according to the Weil Felix titres, most probable disease would be tick borne spotted fever or epidemic typhus, since no louse infestation (the scalp and body infestation, lymphadenopathy) was seen in any of the patients, and most of them were from rural areas more chances of tick infestation. Hence, tick borne spotted fever is most likely cause but still further definitive investigations like PCR should be done to detect the different rickettsial organisms.

Weil Felix test still remains the most commonly used serological test. It may give false positive reactions with Proteus sp., Leptospirosis, Borrelia and severe liver disease. It is negative for R. pox, R. quintana, with Brill-zinsser disease. Even though sensitivity and WF test is low, there are several reports which suggest good co-relation of it with clinical suspicion and other tests. Immunoflourence Assay is taken as gold standard test as it is most sensitive and most specific, but it is too costly for us and even not available easily.

The patients with late presentation, were in altered sensorium, with predominant neurological features. They had poor outcome as compared to those who had received doxycycline prophylactically.

In our study we had few cases with test for dengue fever positive, few with septicemia, etc. Though these were excluded from study, it was observed that the prognosis was poor in such cases.

Conclusions:
  • Rickettsial fever does exist in our area and its incidence is rising.
  • The diagnosis of rickettsia should always be kept in mind for workup of exanthematous fever.
  • High index of clinical suspicion and good laboratory co-relation are helpful in detection of more no of cases.
  • Early diagnosis and treatment with doxy and chloramphenicol can reduce the hospital stay and cost. Associated mixed infections may mislead diagnosis and are more fatal.
  • Weil Felix test is not absolute and should be interpreted in good clinical context, still it remain good screening test, easily available to all.
  • Use of empirical treatment may be considered to reduce the morbidity and mortality observed with this disease.
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