Rare presentation of Typhus Fever with multiorgan failure and Disseminated Intravascular Coagulation

A 46 years old female found to be unconscious at home and brought by neighbours. On admission her GCS was 9. Airway was patent with normal breathing pattern. She tachycardic with low volume pulse and bloodpressure is 60/40mmHg. She was febrile on admission. During resuscitation she received fluid boluses up to 1.5 litres (30ml/kg) .Intravenous noradrenaline was commenced to maintain BP. On examination both lungs breath sounds were equal, vesicular breathing and there were occasional crepitations. There was an eschar on the abdominal wall.


Introduction
Typhus is the group of infectious diseases that includes epidemic typhus,endemic typhus and scrub typhus. Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushii and transmitted by the bite of larval trombiculid mites. Epidemic typhus caused by Rickettsia prowazekki and spread by body lice. Endemic typhus is caused by Rickettsia typhi. (1) Scrub typhus is endemic in Northern part of Sri Lanka in Jaffna peninsula. It commonly occurs in the North East Monsoon rain from September to December.
Our patient presented with typhus fever with septic shock, typhus pneumonitis, encephalitis, myocarditis and disseminated intravascular coagulation. Prompt diagnosis and timely antimicrobial therapy and intensive supportive care made the outcome good and the patient recovered completely from all the complications.

Case report
A 46 years old female found to be unconscious at home and brought by neighbours. On admission her GCS was 9. Airway was patent with normal breathing pattern. She tachycardic with low volume pulse and bloodpressure is 60/40mmHg. She was febrile on admission. During resuscitation she received fluid boluses up to 1.5 litres (30ml/kg) .Intravenous noradrenaline was commenced to maintain BP. On examination both lungs breath sounds were equal, vesicular breathing and there were occasional crepitations. There was an eschar on the abdominal wall.
Typhus antibody was performed and it was positive. We suspected typhus encephalitis and started on intravenous chloramphenicol 500mg 6hourly.
On day 3 of admission she developed difficulty in breathing and saturation dropped to 80% in air. She was intubated and artificial ventilation was given.
At the same time she developed increased bleeding tendency during intravenous cannulation. coagulation profile was performed and found to have increased PT,APTT,INR and low fibrinogen level (0.7g/l). Blood picture was performed and it revealed disseminated intravascular coagulation. D-dimer was more than 80mg/l. 12units FFP, 6units cryo, 10units platelets and 1 pint blood transfusion were given during two weeks hospital stay.
At the same time 2D echo was performed and it suggested global hypokinesia and Troponin I was positive. She was discharge on day 18 with normal coagulation profile and 2DEcho.

Discussion
Typhus fever has been described since 1528AD which can present with multi organ dysfunction. (4) Typhus presents with fever, headache, rash, myalgia, lymphadenopathy and eschar. Nearly all patients presented with fever and 60percentage presented with eschar. (2) The name typhus comes from the greek tuphos meaning hazy, describing the state of mind of those infected. Investigations typically show mild leukocytosis, thrombocytopenia, low albumin and haematocrit. In mild diseases without other organ dysfunction Doxycycline is the drug of choice.(3) Intravenous benzyl penicillin is also effective but in typhus encephalitis intravenous chloramphenicol is the drug of choice. The serious complications of typhus were studied at the year of 1998 in Taiwan at Taipei National Defense Medical centre from August 1993 to July 1997 revealed that 36 percentage of them presented with pneumonitis,15 percentage with ARDS. (8) Our patient presented with septic shock, low GCS and dehydration. Eventhough our patient has a complicated course of illness she recovered fully with time diagnosis with ICU and supportive care.