title: Five-year analysis of rickettsial fevers in children in South India: Clinical manifestations and complications.
abstract: BACKGROUND
  Rickettsial infections are re-emerging in the Indian subcontinent, especially among children. Understanding geographical and clinical epidemiology will facilitate early diagnosis and management.
  
  
  METHODS
  Children aged <18yrs hospitalized with clinically-diagnosed rickettsial fever were reviewed retrospectively. Frequency distributions and odds ratios were calculated from tabulated data.
  
  
  RESULTS
  Among 262 children hospitalized between January 2008-December 2012, median age was five years, and 61% were male children. Hospitalized cases increased steadily every year, with the highest burden (74%) occurring between September and January each year. Mean duration of fever was 11.5 days. Rash was present in 54.2% (142/262) of children, with 37.0% involving palms and soles. Prevalence of malnutrition was high (45% of children were underweight and 28% had stunting). Retinal vasculitis was seen in 13.7% (36/262), and the risk appeared higher in females. Severe complications were seen in 29% (purpura fulminans, 7.6%; meningitis and meningoencephalitis, 28%; septic shock, 1.9%; acute respiratory distress syndrome, 1.1%). Complications were more likely to occur in anemic children. Positive Weil-Felix test results (titers ≥1:160) were seen in 70% of cases. Elevated OX-K titers suggestive of scrub typhus were seen in 80% (147/184). Patients were treated with chloramphenicol (32%) or doxycycline (68%). Overall mortality among hospitalised children was 1.9%.
  
  
  CONCLUSIONS
  This five-year analysis from southern India shows a high burden and increasing trend of rickettsial infections among children. The occurrence of retinal vasculitis and a high rate of severe complications draw attention to the need for early diagnosis and management of these infections.
authors.affiliation: St Johns' Medical College Hospital, Bangalore, India. rwituja.thomas@gmail.com.
authors.forename: Rwituja
authors.initials: R
authors.lastname: Thomas
authors.forename: Preeti
authors.initials: P
authors.lastname: Puranik
authors.forename: Bhuvanesh
authors.initials: B
authors.lastname: Kalal
authors.forename: Carl
authors.initials: C
authors.lastname: Britto
authors.forename: Savitha
authors.initials: S
authors.lastname: Kamalesh
authors.forename: Sylvan
authors.initials: S
authors.lastname: Rego
authors.forename: Anita
authors.initials: A
authors.lastname: Shet
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003710:Demography; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D008297:Male; D015995:Prevalence; D031300:Retinal Vasculitis / Q000453:epidemiology / Q000473:pathology; D012189:Retrospective Studies; D012288:Rickettsiaceae Infections / Q000150:complications / Q000453:epidemiology* / Q000473:pathology*