Rickettsia with Atypical Presentation in Rural Population
Vaishnavi Gurumurthy1*, Gauri Jain2
1Department of PID, Indian Council of Medical Research-NIIH, Mumbai, India
2Emergency Department, Ashoka Medicover Hospital, Nashik, India
*Corresponding Author: Dr. Vaishnavi Gurumurthy, Indian Council of Medical Research- NIIH, 13th floor, New Multistoreyed building, KEM Hospital Campus, Parel, Mumbai-400012, India.
Received: 11 December 2022; Accepted: 30 December 2022; Published: 20 January 2023
Citation: Vaishnavi Gurumurthy, Gauri Jain. Rickettsia with Atypical Presentation in Rural Population. Archives of Clinical and Medical Case Reports 7 (2023): 18-19.View / Download Pdf Share at Facebook
Rickettsia species are small, Gram-negative bacilli that are obligate intracellular parasites of eukaryotic cells. Incidence of Rickettsia have been found in various states of India. Over the last decade, there has been rising incidence of Rickettsia infection in the rural population of Indian subcontinent. The pathogenesis of Rickettsia is varied because of which there are high chances of atypical presentation to the hospital. One such atypical symptom is edema. Due to inflammation of endothelial cells of the blood vessel, extravasation of fluid occurs causing edema and acute kidney injury.
Bipedal Edema; Doxycycline; Rickettsia; Rash
Ticks, lice, fleas, mites, chiggers, and mammals are hosts to a variety of Gram-negative, obligately intracellular bacteria called rickettsiae . Scrub typhus and Indian tick typhus are the most frequent rickettsial infections to have been reported from India thus far. Cases have been reported in increasing numbers over the past ten years. In fact, it has been proven that rickettsial infections are zoonotic bacterial infection that is reemerging in the Indian subcontinent. However, due to a number of factors, including difficulty in diagnosing infections due to inadequate diagnostic tests, low index of clinical suspicion due to nonspecific signs and symptoms, and lack of awareness among healthcare professionals, all cases reported so far from India are an underestimate . These zoonotic pathogens cause infections that disseminate in the blood to many organs. Rickettsia and Orientia species are transmitted by the bite of infected ticks or mites or by the feces of infected lice or fleas. Through the bloodstream, rickettsiae spread from the skin's portal of entry to infect the endothelium and occasionally the vascular smooth muscle cells and reticuloendothelial cells [1,3]. Herein we discuss a case where a woman presenting with fever, splenomegaly and bipedal edema and developing rash during her hospital stay and how Rickettsia came to be diagnosed.
2. Case History
A 72 year old woman presented to the Emergency Department with complaints of fever with chills, increased urination, generalised fatigue, bipedal edema and myalgia accompanied with a history of remote insect bite. Admission was decided on the fact that she had unremitting fever for the last 5 days along with bite history. On admission routine blood tests such as CBC, RFT, CRP and USG abdomen was ordered. On admission the values were Hb- 9.3 mg/dl, TLC- 13,300 cells/mm3, platelet- 2,25,000/mm3, CRP-54 mg/dL. Renal function test revealed serum creatinine level of 1.42, BUN of 40mg/dL and proteinuria of 1+. USG abdomen revealed hepatomegaly with splenomegaly. The patient was admitted to the wards and empiric treatment was started. On day 2 of admission, she developed rashes in her upper extremity, torso and lower extremity. Blood tests were drawn for PCR tests wherein checking for infectious causes such as malaria, dengue, typhoid and rickettsia were done. She was immediately started on Inj. Doxycycline 100 mg in 100cc BD with fluid restriction of 1.5L/day and fever reducer. On day 3 of admission, PCR came positive for Rickettsia. Retesting of CRP showed a level of 157 mg/dL. She was continued with Inj. Doxycycline for the next 7 days and her fever, rash and edema improved over time.
Numerous rickettsial species have shown signs of being dangerous to humans. On the other hand, many other species, some of which may be weakly pathogenic, have not shown any evidence of being pathogenic to humans. Although a number of potential factors have been put forth as contributing to rickettsiae's pathogenicity, the precise molecular basis for this pathogenicity has not yet been determined . The pathogenic sequence of events that occur in rickettsial infection begins with the entry of organisms inoculated by the feeding tick or mite or scratched into the skin from infected louse or flea feces deposited on the skin. The rickettsiae then spread via lymphatic vessels to the regional lymph nodes as has been observed vividly in the lymphangitis associated with R. sibirica mongolitimoniae infection . Rickettsiae then spread hematogenously throughout the body and infect mainly endothelial cells, but also to a lesser extent, macrophages, in the skin, lungs, brain, liver, gastrointestinal tract, kidneys, heart, and other organs. The fundamental lesion of rickettsial diseases is vasculitis, which comprises the events that follow rickettsial infection and activation of endothelium and subsequent spread to involve focal continuous networks of endothelial cells mainly of the microcirculation [1,5]. These lesions form the basis for the rash, which progresses from macules to maculopapules with the accumulation of interstitial edema, and subsequently to petechial lesions with extravasation of blood around the most intensely infected networks of microcirculation in the center of the maculopapules. The pathophysiologic events can be attributed principally to rickettsia infection-associated increased vascular permeability leading to edema, hypovolemia, hypotension, reduced perfusion of organs, acute respiratory distress syndrome, and CNS abnormalities . The patient encountered above had a similar course of events when she developed bipedal edema on presentation without rash. Because of the extravasation of fluid, this patient can be witnessed as having acute kidney injury evidenced by the increased serum creatinine and urea levels. Although she was normotensive, it was evident that she had reduced perfusion of organs. This presentation can diverge the course of treatment as mistreatment or misdiagnose. Keeping in mind the resurgence of Rickettsia in the Indian subcontinent mainly in the rural population, one must look out for various symptoms not only pointing towards it but also the atypical symptoms and do timely testing for prompt treatment.
The pathogenesis of Rickettsia is varied because of which patients can present with variety of symptoms outside of textbook knowledge. Physicians must be aware and keep in mind this fact and get PCR testing done as early as possible to tackle the rising numbers of Rickettsia in rural population of India. Due to inflammation and vasculitis there are high chances of presenting with edema before the development of rash; which is pathognomic of Rickettsia. Such symptoms must not be missed and training to the healthcare providers must be done to create awareness; especially those working at the periphery to consider rickettsial infections as one of the important causes of PUO. In view of low index of suspicion, nonspecific signs and symptoms, and absence of widely available sensitive and specific diagnosic test, these infections are notoriously difficult to diagnose. Failure of timely diagnosis leads to significant morbidity and mortality.
No funding received from any organization.
Conflict of Interest
None to declare.
- Walker DH. Rickettsiae. In: Baron S, editor. Medical Microbiology. 4th edition. Galveston (TX): University of Texas Medical Branch at Galveston; Chapter 38 (1996).
- Sharma A, Mishra B. Rickettsial disease existence in India: resurgence in outbreaks with the advent of 20th Indian J Health Sci Biomed Res 13 (2020): 5-10.
- Rathi N, Rathi A. Rickettsial infections: Indian perspective. Indian Pediatr 47 (2010): 157-164.
- Tsuneo U. Tropism and Pathogenicity of Rickettsiae. Frontiers in Microbiology 3 (2012).
- Sahni A, Fang R, Sahni SK, et al. Pathogenesis of Rickettsial Diseases: Pathogenic and Immune Mechanisms of an Endotheliotropic Infection. Annu Rev Pathol 14 (2019): 127-152.
"Kama ilivyoelezwa katika makala ya ""Kupatikana kwa Vifaa vya Ulinzi wa Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya ya Afya.""" Imepokelewa: Desemba 11, 2022; Kukubaliwa: Desemba 30, 2022; Kuchapishwa: Januari 20, 2023 Quotation: Vaishnavi Gurumurthy, Gauri Jain. Rickettsia na Uwasilishaji wa Atypical katika Idadi ya Vijijini. "Kichwa cha habari cha ""Clinical and Medical Case Reports"" cha mwaka wa 2023, kinaonyesha kwamba aina ya Rickettsia ni aina ndogo ya bakteria ya Gram-negative ambayo ni vimelea vya ndani ya chembe za eukaryotic." Matukio ya Rickettsia yamepatikana katika majimbo mbalimbali ya India. Katika miaka ya hivi karibuni, idadi ya watu walioambukizwa na Rickettsia imeongezeka katika maeneo ya vijijini ya India. Ugonjwa wa Rickettsia ni tofauti kwa sababu ya ambayo kuna nafasi kubwa ya uwasilishaji wa atypical kwa hospitali. Mojawapo ya dalili hizo zisizo za kawaida ni uvimbe. Kwa sababu ya uvimbe wa seli za endothelial za mishipa ya damu, extravasation ya kioevu hutokea kusababisha edema na jeraha kali la figo. Doxycycline, Rickettsia, na Rash: Ticks, lice, fleas, mites, chiggers, na mamalia ni majeshi ya aina mbalimbali ya Gram-negative, lazima bakteria intracellular aitwaye rickettsiae. Tifo ya scrub na typhus ya tick ya India ni maambukizo ya rickettsial ya mara kwa mara zaidi ambayo yameripotiwa kutoka India hadi sasa. Katika miaka kumi iliyopita, idadi ya visa hivyo imeongezeka. Kwa kweli, imethibitishwa kwamba maambukizo ya rickettsial ni maambukizo ya bakteria ya zoonotic ambayo yanaibuka tena katika bara la India. Hata hivyo, kutokana na sababu kadhaa, ikiwa ni pamoja na ugumu wa kugundua maambukizi kutokana na vipimo vya utambuzi visivyo vya kutosha, kiwango cha chini cha mashaka ya kliniki kutokana na dalili zisizo za kawaida, na ukosefu wa ufahamu kati ya wataalamu wa huduma za afya, kesi zote zilizoripotiwa hadi sasa kutoka India ni chini ya takwimu. Vimelea hivyo husababisha maambukizo ambayo huenea katika damu hadi kwenye viungo vingi. Rickettsia na Orientia zinapatikana kwa kuumwa na chungu au chungu au kwa kutapika kwa chungu au chungu. Katika mfumo wa damu, rickettsiae huenea kutoka kwa mlango wa kuingia kwa ngozi kuambukiza endothelium na wakati mwingine seli za misuli laini ya mishipa na seli za reticuloendothelial. Katika kesi hii, mwanamke mmoja alikuwa na homa, splenomegaly na edema ya bipedal na alikuwa na ugonjwa wa rash wakati wa kukaa kwake hospitalini. 2. Uwezekano wa kupata Mwanamke mwenye umri wa miaka 72 alilazimika kwenda kwenye idara ya dharura na malalamiko ya homa na baridi, kuongezeka kwa mkojo, uchovu wa jumla, edema ya bipedal na myalgia, pamoja na historia ya kuumwa na wadudu. Ugonjwa huo ulisababishwa na kuwa na homa ya juu kwa siku tano na historia ya kuumwa. Baada ya kuwasili, uchunguzi wa kawaida wa damu kama vile CBC, RT-PCR, na USG ulifanywa. Wakati wa kuingia, viwango vya Hb vilikuwa 9.3 mg DL, TLC 13.300, platelets 2.25 mg DL, CRP 54 mg DL. Utafiti wa kazi ya figo ulionyesha kiwango cha seramu ya creatine ya 1.42 na BUN ya 40mg na proteinuria ya 1+. Ugonjwa wa tumbo ulionyesha hepatomegaly na splenomegaly. Mgonjwa huyo alilazwa katika wadi na matibabu ya empiric yalianza. Siku ya pili baada ya kuingizwa, alipata mlipuko katika sehemu ya juu ya mwili, mwili na sehemu ya chini ya mwili. Mtihani wa damu wa PCR ulifanywa na kugundua sababu za kuambukiza kama vile malaria, homa ya dengue, homa ya typhoid na rickettsia. Mara moja alianza kutumia Inj. Doxycycline 100 mg katika 100 cc ya damu, na kupunguza maji ya 1.5L kwa siku na kupunguza homa. Siku ya tatu baada ya kuwasili, PCR ilionyesha kuwa alikuwa na ugonjwa wa Rickettsia. Utafiti wa CRP ulionyesha kiwango cha 157 mg kwa dL. Aliendelea na Inj. Doxycycline kwa siku saba zilizopita na homa yake, kuvu na uvimbe uliboreshwa kwa muda. Spishi nyingi za rickettsial zimeonyesha dalili za kuwa hatari kwa wanadamu. Kwa upande mwingine, spishi nyingine nyingi, ambazo baadhi ya zinaweza kuwa na vimelea vidogo, hazijaonyesha uthibitisho wowote wa kuwa na vimelea vidogo kwa wanadamu. Ingawa idadi ya sababu za uwezekano zimetolewa kama kuchangia rickettsiae's pathogenicity, msingi sahihi wa molekuli kwa ajili ya pathogenicity hii bado haijaamuliwa. Mfuatano wa matukio ya pathogenic ambayo hutokea katika maambukizo ya rickettsial huanza na kuingia kwa viumbe vilivyochukuliwa na kuota tick au mite au scratched katika ngozi kutoka kwa chafu au chafu iliyoambukizwa iliyowekwa kwenye ngozi. Rickettsiae kisha kuenea kupitia mishipa ya lymphatic kwa nodes lymph kikanda kama imekuwa aliona vividly katika lymphangitis kuhusishwa na R. sibirica mongolithomoniae maambukizi. Rickettsiae huenea kwa njia ya damu katika mwili wote na kuambukiza hasa seli za endothelial, lakini pia kwa kiwango kidogo, macrophages, katika ngozi, mapafu, ubongo, ini, mfumo wa gastrointestinal, figo, moyo, na viungo vingine. Vipimo vya msingi vya ugonjwa wa rickettsial ni vasculitis, ambayo inajumuisha matukio ambayo hufuata maambukizo ya rickettsial na uanzishaji wa endothelium na kuenea kwa baadaye kujumuisha mitandao ya mfululizo ya seli za endothelial hasa ya mzunguko mdogo. Matatizo haya huunda msingi wa mlipuko, ambao huendelea kutoka maculus hadi maculopapules na mkusanyiko wa edema ya interstitial, na baadaye kwa majeraha ya petechial na extravasation ya damu karibu na mitandao ya microcirculation yenye kuambukizwa zaidi katikati ya maculopapules. Matukio ya pathophysiological yanaweza kuhusishwa hasa na uharibifu wa mishipa ya damu unaohusishwa na maambukizo ya rickettsia, na kusababisha edema, hypovolemia, hypotension, kupunguzwa kwa perfusion ya viungo, ugonjwa wa shida ya kupumua, na kasoro za CNS. Mgonjwa aliyekutana hapo juu alikuwa na mwendo sawa wa matukio wakati alipokuwa na uvimbe wa miguu miwili wakati wa uwasilishaji bila mchochota. Kwa sababu ya extravasation ya kioevu, mgonjwa huyu anaweza kushuhudiwa kama kuwa na uharibifu wa figo kali kuthibitishwa na kuongezeka kwa viwango vya seramu creatinine na urea. Ingawa alikuwa na shinikizo la damu la kawaida, ilikuwa wazi kwamba alikuwa amepunguza usafirishaji wa viungo. Maonyesho haya yanaweza kutofautisha mwendo wa matibabu kama matibabu mabaya au utambuzi mbaya. Kwa kuzingatia kuongezeka kwa Rickettsia katika bara la India, haswa katika idadi ya watu wa vijijini, mtu lazima angalie dalili mbalimbali ambazo hazionyeshi tu lakini pia dalili zisizo za kawaida na kufanya upimaji wa wakati unaofaa kwa matibabu ya haraka. Ugonjwa wa Rickettsia ni tofauti kwa sababu ambayo wagonjwa wanaweza kuwasilisha na dalili mbalimbali nje ya maarifa ya kitabu cha masomo. "Daktari lazima wawe na ufahamu na kukumbuka ukweli huu na kupata upimaji wa PCR mapema iwezekanavyo ili kukabiliana na idadi inayoongezeka ya Rickettsia katika idadi ya vijijini vya India. """ Kwa sababu ya uvimbe na vasculitis kuna nafasi kubwa ya kuwasilisha na edema kabla ya maendeleo ya rash; ambayo ni pathognomic ya Rickettsia. "Hata hivyo, ni muhimu kuwahakikishia wagonjwa na wataalamu wa afya, hasa wale wanaofanya kazi katika maeneo ya mbali, kwamba ""kuchukua virusi vya rickettsial ni moja ya sababu muhimu za ugonjwa wa UTI.""" Kwa kuzingatia kiwango cha chini cha tuhuma, dalili zisizo za kawaida, na ukosefu wa upimaji wa utambuzi wa kina na maalum, maambukizi haya ni magumu sana kugundua. Kushindwa kugundua ugonjwa huo kwa wakati unaofaa husababisha ugonjwa na vifo vingi. Hakuna ufadhili uliopokelewa kutoka kwa shirika lolote. Mgogoro wa maslahi Hakuna kutangaza. - DH Walker. Rickettsiae. Katika: Baron S, mhariri. Microbiolojia ya Kitiba. Toleo la nne. Galveston, Texas: Chuo Kikuu cha Texas Medical Branch katika Galveston; Sura ya 38 (1996). "Mwanamke huyo, ambaye pia ni mwanasayansi wa afya, aliandika: ""Ugonjwa wa Rickettsial unaoenea nchini India: Kuongezeka kwa milipuko ya ugonjwa huo na kuibuka kwa J Health Sci Biomedical Resolution 13 (2020): 5-10." - Rathi N, Rathi A. Maambukizo ya Rickettsial: mtazamo wa Kihindi. Ugonjwa wa watoto wa India 47 (2010-2014) - Tsuneo U. Tropism na Pathogenicity ya Rickettsiae. Frontiers katika Microbiology 3 (2012) - Sahni A, Fang R, Sahni SK, et al. Pathogenesis ya magonjwa ya Rickettsial: Pathogenic na Immunological Mechanisms ya Endotheliotropic Infection. Anu Rev Patel 14 (mwaka 2019)