Aftermath Earthquake in Nepal: Burden of Scrub Typhus Cases and their Presentations

Background: Scrub typhus, also known as tsutsugamushi disease, is an infectious illness caused by Orientia (Rickettsia) tsutsugamushi. It is widely found in Asian counztries and human beings of all ages including children are influenced by it. It can cause death due to late presentation, delayed diagnosis and drug resistance. The clinical features and complications of scrub typhus vary from mild to fatal illness. We describe the epidemiology, clinical features and treatment outcome among scrub typhus cases admitted in Sukraraj Tropical and Infectious Disease Hospital (STIDH), a tertiary center in Kathmandu, Nepal following the massive earthquake of 2015. Material and methods: Serum samples of twenty-three patients with acute undifferentiated fever admitted to the STIDH were tested positive for orientia tsutsugamushi by IgM ELISA. These patients were admitted between August to October 2015. Detail history taking, clinical evaluation and laboratory parameters of these patients were collected. Most of the patients were from the earthquake effected district and staying in temporary shelter with history of rodent infestation of the environment. Verbal consent was taken from each patient. The data were entered in SPSS version 16 and descriptive statistics was used to analyze the data. Results: In the study, more than half of the patients (52.2%) were female and the mean (±SD) age of the patients was 37.6 (±13.3) years. Most of the patients (82.7%) were engaged in farm work. About three fifths (60.8%) of the patients were from Dhading district followed by Nuwakot, Sarlahi, Kavre and Parsa. Except Sarlahi district, all other were affected by earthquake 2015. Majority (87%) of the patients were living in the temporary shelter following devastating earthquake and had history of environmental infestation by rodents. All the patients had fever and anorexia. The mean fever duration before admission was 10.1(±4.0) days. Clinical features of arthralgia and myalgia (91.3%); nausea, headache and chills or rigors (82.6%) and retroorbital pain (60.9%) among the commonest. Abdominal pain and cough was complained by 47.8% and 43.5% patients respectively. Eschar formation, red eye and lymphadenopathy were the commonest physical finding and noted in 30.4, 30.4% and 26.1% patients respectively. Lymphadenopathy was localized. Most common laboratory parameter was increased in alanine transaminase level and thrombocytopenia and was seen in 73.9% and 60.9% patients respectively. Leukocytosis was seen in 21.7% of patients. Azithromycin or doxycycline was added on ceftriaxone once the diagnosis of scrub typhus was made. The mean fever response time was 1.7 (±1.2) days. All patients were discharged after fever subsides. Clinical recovery and hospital stay was uneventful. Conclusion: From the study, it can be concluded that scrub typhus has emerged as an important cause of febrile illness in Nepal after massive earthquake of 2015 so; it demands the continuous surveillance in the health care setting. Scrub typhus should be considered in the patient presenting with acute undifferentiated fever and can be confirmed by sensitive test as characteristic clinical findings seen only in small number of cases. Rodent infestation of the environment around temporary shelter increases the risk of acquiring scrub typhus and such history increases clinical suspicion in the diagnosis. Azithromycin and doxycycline are the effective antibiotics. Appropriate diagnosis and treatment can reduce the complication of scrub typhus even in resource-limited environment.