title: Clinical profile and improving mortality trend of scrub typhus in South India.
abstract: BACKGROUND
  Scrub typhus, a bacterial zoonosis caused by Orientia tsutsugamushi, may cause multiorgan dysfunction syndrome (MODS) and is associated with significant mortality. This study was undertaken to document the clinical and laboratory manifestations and complications and to study time trends and factors associated with mortality in patients with scrub typhus infection.
  
  
  METHODS
  This retrospective study, done at a university teaching hospital, included 623 patients admitted between 2005 and 2010 with scrub typhus. The diagnosis was established by a positive IgM ELISA and/or pathognomonic eschar with PCR confirmation where feasible. The clinical and laboratory profile, course in hospital, and outcome were documented. Factors associated with mortality were analyzed using multivariate logistic regression analysis.
  
  
  RESULTS
  The most common presenting symptoms were fever (100%), nausea/vomiting (54%), shortness of breath (49%), headache (46%), cough (38%), and altered sensorium (26%). An eschar was present in 43.5% of patients. Common laboratory findings included elevated transaminases (87%), thrombocytopenia (79%), and leukocytosis (46%). MODS was seen in 34% of patients. The overall case-fatality rate was 9.0%. Features of acute lung injury were observed in 33.7%, and 29.5% required ventilatory support. On multivariate analysis, shock requiring vasoactive agents (relative risk (RR) 10.5, 95% confidence interval (CI) 4.2-25.7, p<0.001), central nervous system (CNS) dysfunction (RR 5.1, 95% CI 2.4-10.7, p<0.001), and renal failure (RR 3.6, 95% CI 1.7-7.5, p=0.001) were independent predictors of mortality. Over 4 years, a decreasing trend was observed in the mortality rate.
  
  
  CONCLUSIONS
  Scrub typhus can manifest with potentially life-threatening complications such as lung injury, shock, and meningoencephalitis. MODS occurred in a third of our patients. The overall case-fatality rate was 9%, with shock, renal failure, and CNS associated with a higher mortality.
authors.affiliation: Medicine Unit I and Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India. Electronic address: georgemvarghese@hotmail.com.
authors.forename: George M
authors.initials: GM
authors.lastname: Varghese
authors.affiliation: Department of Infectious Diseases, Tufts University, Boston, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Trowbridge
authors.affiliation: Medicine Unit I and Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: Jeshina
authors.initials: J
authors.lastname: Janardhanan
authors.affiliation: Medicine Unit I and Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: Kurien
authors.initials: K
authors.lastname: Thomas
authors.affiliation: Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: John V
authors.initials: JV
authors.lastname: Peter
authors.affiliation: Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: Prasad
authors.initials: P
authors.lastname: Mathews
authors.affiliation: Medicine Unit I and Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: Ooriapadickal C
authors.initials: OC
authors.lastname: Abraham
authors.affiliation: Department of Hematology, Christian Medical College, Vellore, Tamil Nadu, India.
authors.forename: M L
authors.initials: ML
authors.lastname: Kavitha
mesh_terms: D000328:Adult; D004797:Enzyme-Linked Immunosorbent Assay; D005260:Female; D006801:Humans; D007075:Immunoglobulin M / Q000097:blood; D007194:India / Q000453:epidemiology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality; D015999:Multivariate Analysis; D012285:Orientia tsutsugamushi / Q000302:isolation & purification; D016133:Polymerase Chain Reaction; D012189:Retrospective Studies; D012612:Scrub Typhus / Q000150:complications / Q000175:diagnosis* / Q000401:mortality*
chemical_list: D007075:Immunoglobulin M
keywords: ARDS; Mortality trends; Multiorgan dysfunction syndrome; Scrub typhus