Thread by @RosenelliEM

Another @CPSolvers Virtual Morning Report in the books. The more of these I do, the less I feel like I know. The learning journey is Fantastic. So what did I learn?

Fever in a Returning Traveler & a lot about #Dengue & #OrientiaTsutsugamushi. Wait, What?
clinicalproblemsolving.com/wp-content/upl…

Thanks @rabihmgeha for this gem! O. tsutsugamushi is caused by Scrub typhus which is a mite-borne infectious disease.

It was 1st described by the Chinese in the 3rd century, but its classic features did not appear in the western literature until the end of the 19th

O. tsutsugamushi is a gram-negative coccobacillus that is antigenically distinct from the typhus group rickettsiae. Oh yes, Doxy to the rescue. It's endemic in Korea, China, Taiwan, Japan, Pakistan, India, Thailand, Malaysia, and Australia.

A good ddx for this includes malaria, dengue, leptospirosis, and other rickettsial diseases.

The reservoir and vector of scrub typhus are larval trombiculid mites or "chiggers" of the genus Leptotrombidium. The disease is imported in tourists returning from endemic areas.

Symptoms can begin insidiously with headache, anorexia, and malaise, or start abruptly with chills and fever. As the illness evolves, most patients develop a high fever (14 days is median), worsening of headache, and myalgias. Some will have evidence of bites as seen below.

If you find this on you, please remove

A painless papule often appears at the site of the infecting chigger bite. Subsequent central necrosis then occurs, which in turn leads to the formation of a characteristic eschar with a black crust.

Approximately one-half of all patients develop a characteristically nonpruritic, macular or maculopapular rash. The rash typically begins on the abdomen and spreads to the extremities. The face is also often involved.

The severity of infection can range from mild to multiorgan failure with the elderly more susceptible. Localized, and subsequent generalized lymphadenopathy, occurs in the majority of patients. Inflammation of the lymphatic sinuses, splenomegaly, & portal triaditis.

The indirect fluorescent antibody test remains the gold standard; a four-fold rise in titers over a 14-day period is conclusive. Culture and (PCR) testing is only available in specialized research facilities. A skin biopsy will show a lymphohistiocytic vasculitis.

Doxycycline for 7 days and chloramphenicol are good treatment options. Chloramphenicol is associated with significant drug toxicity, such as bone marrow suppression. If you don't want to consult @Anand_88_Patel then I suggest Doxy! Azithromycin is an alternative in pregnant women