Polyarthritis: An Unusual Presentation of Scrub Typhus

Piyush Gautam; Nivedita Sharma

doi:https://10.7199/ped.oncall.2018.26

Piyush Gautam, Nivedita Sharma.

Department of Pediatrics, Dr Rajendra Prasad Medical College and Hospital, Tanda, Kangra, Himachal Pradesh.

ADDRESS FOR CORRESPONDENCE
Dr Nivedita Sharma, Department of Pediatrics, Dr Rajendra Prasad Medical College and Hospital, Tanda at Kangra, Himachal Pradesh, India.
Email: niveditasharma2@yahoo.com

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Scrub typhus is an acute febrile illness caused by infection with Orientia tsutsugamushi. (1) The clinical picture of scrub typhus consists of mainly fever, rash, myalgia and lymphadenopathy with or without organ involvement. (2) The pathognomonic features such as eschar and lymphadenopathy are seen in 50% of patients. The course of this disease may be complicated by acute respiratory distress syndrome (ARDS), acute hepatitis, acute renal failure, meningoencephalitis, disseminated intravascular coagulation, shock and myocarditis. (3) There is one report of polyarthritis and massive small bowel bleed in a patient with scrub typhus. (4) We present a child with scrub typhus who presented with only fever and polyarthritis.
A 10 years old girl presented with pain and swelling in the joints of lower limbs for 3 days and fever for one day. Pain and swelling started from left ankle joint which was sudden in onset and subsequently involved right and left knee joints by next morning. Fever was intermittent reaching upto 1020F. There was no sore throat, rash or burning micturition. On examination, vital parameters were stable and musculoskeletal examination revealed swelling, redness in left ankle and both the knee joints. Other systems were normal. The temperature over the joints was increased and movements were restricted. Clinically considering a diagnosis of acute rheumatic fever, the child was started on aspirin. However she developed right hip and elbow joint involvement on second day of hospitalization. Investigations revealed hemoglobin 12.4gm/dl, white cell count 21300 cells/cumm and erythrocyte sedimentation rate (ESR) 50 mm at end of 1 hour. CRP was positive (48 mg/dl), Antistreptolysin O (ASO) titre was < 200 IU/ml. Rheumatoid factor was negative. Ultrasonography of the joints showed thickening of the capsules with minimal effusion. Echocardiography was normal. Since our area is a scrub typhus endemic zone, scrub typhus IgM ELISA (Lubois International Inc) was sent which was positive. She was started on doxycycline which was given for 5 days. Fever defervescence occurred and arthritis improved. On follow-up the child remained asymptomatic.

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References

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