An unusual presentation of scrub typhus in a child

A report describes a case of a 5-year-old girl, who was previously healthy and presented with a one-week history of high-grade intermittent fever, headache, and right ear pain. She reported paroxysmal right ear pain but without any history of ear discharge, tinnitus, dizziness, or seizures. She also reported experiencing a headache with nausea, but no vomiting or loss of consciousness, which was associated with some abdominal distension and pain. 

Her bowel and urine output was normal, however, she described dysuria. She did not have any history of insect or tick bites even though she usually played in the fields during the day, as her parents were farmers.

On the 7th day after the onset of illness, she complained of diminished hearing in her right ear without tinnitus, which gradually advanced to unilateral hearing loss.

Physical examination revealed a fever of 39 °C and cervical lymphadenopathy, without any evidence of any rash or eschar. Throat examination revealed mildly enlarged tonsils without signs of inflammation. Initial otoscopic examination of her ears was unremarkable. Unilateral right ear sensorineural hearing loss was documented using Weber’s tuning fork test due to the unavailability of audiometric tests. She was mildly tachypneic but did not need oxygen. Bilateral pleural effusion was recorded. Abdominal examination showed mild hepatosplenomegaly.

Laboratory tests revealed thrombocytopenia, mild anemia and slightly raised neutrophils. Thereafter, over the next few days, her platelet counts slowly decreased to a nadir of 47,000 cells/mm3. Her C-reactive protein was noted as 105 mg/dL with an increased erythrocyte sedimentation rate of 20 mm/hr. Urine analysis revealed mild proteinuria. Chest X-ray revealed bilateral pleural effusion with bilateral infiltrates. An abdominal ultrasonogram confirmed mild hepatosplenomegaly. Rapid diagnostic tests (RDT) were negative for leishmaniasis but positive for dengue IgG. SD BIOLINE Tsutsugamushi RDT for scrub typhus was reported to be positive. 

She was initiated empiric treatment with intravenous ceftriaxone and oral doxycycline. On the 6th day of admission, an otoscopic examination was repeated due to continued mild ear pain and worsening hearing impairment, which revealed a chigger mite in the external auditory canal which was promptly removed. Regardless, there was no evidence of otitis media or inner ear abnormalities. Her pain resolved soon after the removal of the mite and her fever 2 days after the initiation of antibiotics.

One-week follow-up showed no residual hearing loss and the complete resolution of otalgia.

Jatsho, J. An unusual presentation of scrub typhus in a child: a case report. BMC Pediatr. 2022, 22. https://doi.org/10.1186/s12887-022-03139-y