title: Clinical and paraclinical profile, and predictors of outcome in 90 cases of scrub typhus, Meghalaya, India.
abstract: BACKGROUND
  India is an integral component of "tsutsugamushi triangle" which depicts a part of the globe endemic to scrub typhus. Owing to frequent outbreaks witnessed in different parts of the country in the recent past, scrub typhus is described as a re-emerging infectious disease in India. The present study aimed to study the clinical and paraclinical profile, complications and predictors of outcome among 90 cases of scrub typhus diagnosed in a hospital of north-eastern India from Sept 2011 to Aug 2012.
  
  
  METHODS
  A longitudinal study was conducted in a hospital of Meghalaya, India between Sept 2011 and Aug 2012. Diagnosis of scrub typhus was arrived by SD BIOLINE tsutsugamushi (solid phase immunochromatographic assay) rapid diagnostic test for antibodies (IgM, IgG or IgA). Descriptive analyses of age, gender, geographic area, symptoms and signs, treatment, laboratory findings, complications, and outcome were conducted. Relative risk (RR) with 95 % confidence interval (CI) was computed for Multiple Organ Dysfunction Syndrome (MODS) and mortality. Binary logistic regression was applied to the significant correlates (P < 0.05) on univariate analysis to identify the predictors of MODS and mortality in scrub typhus.
  
  
  RESULTS
  As many as 662 clinically suspected scrub typhus patients were tested and 90 (13.6 %) were diagnosed to have scrub typhus. Out of 90 patients, 52.2 % (n = 47) were males and their mean (SD) age was 36.29 (13.38) years. Fever of <7 days (n = 75, 83.3 %), myalgia (n = 56, 62.2 %), pain abdomen (n = 24, 26.7 %), headache (n = 24, 26.7 %), nausea/vomiting (n = 21, 23.3 %), dry cough (n = 21, 23.3 %), hepatomegaly (n = 24, 26.7 %), splenomegaly (n = 22, 24.4 %), and lymphadenopathy (n = 20, 22.2 %) were the predominant clinical features. Eschar was seen in 10 patients (11.1 %). One third (n = 30) of the patients developed at least one systemic complication. Acute hepatitis (n = 15, 16.7 %), pneumonitis (n = 14, 15.6 %), and acute kidney injury (n = 11, 12.2 %) were the common complications. MODS was seen in 14.4 % (n = 13) and 38.5 % (n = 5) of the patients with MODS died. Overall, case fatality rate was 5.15 % (n = 5). On univariate analysis, platelets <100 000/mm3, serum creatinine >1.5 mg/dl, and transaminase (AST, ALT or both) >500 U/L were associated with MODS (P < 0.001) and mortality (P < 0.05). In addition, serum bilirubin >3 mg/dl was also associated with MODS (P < 0.001). On applying binary logistic regression, serum creatinine >1.5 mg/dl was a predictor of MODS (OR: 76.1, 95 % CI: 4.9-1175.6) and mortality (OR: 18.03, 95 % CI: 1.38-235.1).
  
  
  CONCLUSIONS
  In this study setting, approximately one-seventh (13.6 %) of the acute undifferentiated febrile illness were due to scrub typhus. Systemic complications were common (33.3 %). Serum creatinine >1.5 mg/dl was a predictor of MODS and mortality.
authors.affiliation: Department of General Medicine, Nazareth Hospital, Shillong, 793003, Meghalaya, India.
authors.forename: Sunuraj
authors.initials: S
authors.lastname: Sivarajan
authors.affiliation: Department of Community Medicine, Yenepoya Medical College, Yenepoya University, Mangalore, 575018, Karnataka, India. shivalli.bhu@gmail.com.
authors.forename: Siddharudha
authors.identifier: http://orcid.org/0000-0003-1454-7114
authors.initials: S
authors.lastname: Shivalli
authors.affiliation: Department of General Medicine, Nazareth Hospital, Shillong, 793003, Meghalaya, India.
authors.forename: Debomallya
authors.initials: D
authors.lastname: Bhuyan
authors.affiliation: Department of Microbiology, Nazareth Hospital, Shillong, 793003, Meghalaya, India.
authors.forename: Michael
authors.initials: M
authors.lastname: Mawlong
authors.affiliation: Department of General Medicine, Nazareth Hospital, Shillong, 793003, Meghalaya, India.
authors.forename: Rittwick
authors.initials: R
authors.lastname: Barman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D021821:Communicable Diseases, Emerging / Q000175:diagnosis / Q000453:epidemiology* / Q000382:microbiology; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D016015:Logistic Models; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D012285:Orientia tsutsugamushi / Q000502:physiology*; D012307:Risk Factors; D012612:Scrub Typhus / Q000175:diagnosis / Q000453:epidemiology* / Q000382:microbiology; D055815:Young Adult
keywords: Hospital; India; Longitudinal; Mortality; Multiple Organ Dysfunction Syndrome (MODS); Scrub typhus