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Interesting case of febrile illness with rash

Interesting case of febrile illness with rash. BY DR.V.PADMA , ASSOCIATE PROFESSOR OF MEDICINE SREE BALAJI MEDICAL COLLEGE. Case : 1.

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Interesting case of febrile illness with rash

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  1. Interesting case of febrile illness with rash BY DR.V.PADMA , ASSOCIATE PROFESSOR OF MEDICINE SREE BALAJI MEDICAL COLLEGE

  2. Case: 1 • A 23 year old male was brought to casualty in unconscious state with ET tube, referred from private hospital. Pt had a history of fever for 9 days , high grade , on and off (remittent fever), With chills and rigor. No H/O Neck Pain , photophobia , seizures ,double vision prior to altered sensorium , Burning micturiction No H/O nausea , vomiting , cough and cold , headache , Pt was irritable N/K/C/O DM , HTN , BA , Past History & Personal history : Not relevent

  3. Vitals: Pulse : 120/mt BP: 150/90 mm HG Temp: 101F SPO2 : 70 % GCS----- E1M3V1

  4. O/E Febrile No lymphadenopathy No clubbing ,cyanosis No icterus CVS- S1 S2 Heard , no added sound , no murmur RS- BAE , No wheezing , no crepitation , no crackles PA – Soft , No palpable mass CNS- NFND Skin leision seen in at 4th rib in mid axillary line

  5. Investigations CBC-- TC 23900 n 81% RFT-- Sr urea 80 mgs/dl Sr creat 2.3 mgs/dl Lepto serology Dengue serology MP, QBC Sr Electrolytes WNL WIDAL HIV I , II Urine R/E C/S Hep B C E viral marker negative CT Brain –Plain LFT SGPT 140 SGOT 58 ABG Initially Pt had resp acidosis Investigation ……. ?

  6. Treatment • Pt was on ventilator support Inj. PIPTAZ 4.5 g IV BD Inj. FALCIGO 120 mg IV 6th 12th Hrly followed by 120mg OD Inj. CP 40 lakhs IV QID No response After INV Tab.Doxy 100mg BD Tab. Levoflox 500mg OD Inj. Ceftrioxone 2 g IV BD Pt died due to Septicemia , MODS ,

  7. Case 2 • 45 year old female came to OPD with C/O intermittent type of fever High grade Chills , nausea , vomiting , Cold and cough with sputum , purulent scanty abdominal pain , constipation O/E Vitals : Conscious Pulse 90/mt Oriented BP 130/90 mm Hg Febrile Temp 102 F lymphadenopathy No clubbing ,cyanosis CVS -S1 S2 Heard , no added sound No icterus RS BAE ,No wheezing , no Crepitation skin lesion seen behind pinna PA –Soft, post auricular node was palpable CNS- NFND

  8. Investigations: CBC-- TC 12600 n 70% RFT-- bl. urea 60 mgs/dl Sr creat 1.1 mgs/dl Lepto serology Dengu serology MP, QBC Sr Electrolytes WNL WIDAL HIV I , II Urine R/E C/S Hep B C E viral marker negetive LFT SGPT 160 SGOT 53 Investigation ……….. ?

  9. Treatment: Inj. Xone 1g IV BD Tab. Doxy 100 mg BD Tab. Azithral 500mg OD

  10. Malaria (stained blood films) Arbovirus infection (dengue) serology test Leptospirosis (PCR/MAT/Serology) Meningococcal disease ( blood and CSF culture) Typhoid (WIDAL, Blood C/S) Wt other Inv can be done ? Rickettsialpox: (agglutination test) Rash appears rapidly consist of sparse macules papules that becomes vesicular before crusting and fading. Mediterranean spotted fever: Eschar with adenitis Scrub Typhus: Black Eschar , central necrosis with red periphery Rocky Mountain spotted fever: Multiple rashes DD

  11. Final Diagnosis • Scrub Typhus

  12. ORGANISM- Rickettsia Orientiatsutsugamushi • RESERVOIR- • TROMBICULID MITE LARVAE (CHIGGER)

  13. EPIDEMIOLOGY • INDONESIA • MAYSIA • PHILIPPINES • AUSTRALIA • INDIA • PAPUA NEW GUINEA • PAKISTAN • MAYANMAR • SRILANKA • JAPAN • S KOREA

  14. RATS and BIRDS MITE HUMAN (Accidental host )

  15. Inoculation Pathogenesis Papule, maculopapular Rash Eschar Enlargement of local lymph node Invade local lymph nodes

  16. Invade to vascular endothilium Toxic symptoms Lymphadenopathy Spread in blood stream

  17. Clinical Manifestation Incubation Period 6 to 10 days SYMPTOMS : Sudden onset of fever Headache, myalgia, cough, GI sypmtoms Tinitus , hyperacusis followed by deafness , constipation , Epistaxis More virulant strain Haemorrhage Intravascular coagulation

  18. SIGNS: 1. Papule, maculopapular rash (1st week) Chest, abdomen, whole trunk , U/L , L/L, rare face, palm and sole Seen in 40% of patients • Eschar (End of 1st week) Seen in 50% of patients Axilla, inguinal area , buttock, Scrotum , thigh • Lymphadenopathy local lymph node (end of 1st week) Generalised lymphadenopathy (end of 2nd week) 4. Hepatosplenomegaly

  19. In serious cases • meningoencephalitis with neck stiffness , delirium , papilloedema can occur . Myocarditis may complicate this phase. Oliguria with uraemia is common in severe cases ARDS and septic shock has also been reported People of areas endemic for Scrub typhus commonly have a less severe illness , often without any rash or Eschar

  20. Complications 1. Pneumonitis due to vascular injury 2.Meningo Encephalitis 3. Multi organ failure , sepsis , toxic syndrome 4. Myocarditis

  21. Investigations 1. IFA (Indirect Fluorescent Antibody) Test Gold standard IgG , IgM 1:40 dilu present 4th day onwards 2. Weil-Felix antigen OX19 R. typhi Ox2 R . ricketsii OxK O.tsutsugamushi

  22. TREATMENT: DOXYCYCLINE 100 mg BD Continue till 48 hrs after fever subsides. AZITHROMYCIN 500 mg OD 7 days RIFAMPICIN 300 BD 7 days FLUOROQUINOLONES 7 days OD/BD Pead and preg women newer Macrolides prophylactic treatment It has been shown that a single oral dose of chloramphenicol or tetracycline given every five days for a total of 35 days, with 5-day non-treatment intervals, actually produces active immunity to scrub typhus. This procedure is recommended under special circumstances in certain areas where the disease is endemic

  23. Vaccine: no effective vaccines for scrub typhus. It is now known that there is enormous antigenic variation in Orientia tsutsugamushi strains, and immunity to one strain does not confer immunity to another. Any scrub typhus vaccine should give protection to all the strains present locally, in order to give an acceptable level of protection. A vaccine developed for one locality may not be protective in another locality, because of antigenic variation. This complexity continues to hamper efforts to produce a viable vaccine

  24. THANK YOU

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