Scrub Typhus Masquerading as Limbic Encephalitis

Abstract

Scrub typhus, an acute febrile infectious disease prevalent in the ‘tsutsugamushi triangle’, is a mite-born rickettsial zoonosis, caused by Orientia tsutsugamushi. The clinical presentation is protean and involves multiple organ systems of the body, including central and peripheral nervous systems. We report a 22-year-old previously healthy Indian woman who presented with clinical (confusion, excessive sleepiness, cognitive dysfunction and focal seizures) and neuroimaging features of limbic encephalitis. After exclusion of common infectious, autoimmune and paraneoplastic causes, she was diagnosed with scrub typhus associated encephalitis, which responded to doxycycline and azithromycin therapy.

A case of acute encephalitis syndrome and cranial nerve palsy secondary to scrub typhus: A rare presentation from Western Nepal

“…The neuroimaging findings for meningoencephalitis due to scrub typhus are quite limited. There have been reports of radio imaging findings of lesions on a white matter involving the subcortical, periventricular deep white matter, corpus callosum, cerebellar peduncles, brain stem, and basal ganglia, as well as gray matter lesion and microhemorrhages 29 . Kar et.…”

Cerebral Venous Sinus Thrombosis Following Scrub Typhus Infection: A Case Report and a Review of the Literature

“…[1][2][3]14 Severe scrub typhus is associated with interstitial pneumonia, renal failure, gastrointestinal bleeding, and CNS manifestations like meningoencephalitis (most common), cerebral infarction, transverse myelitis, movement disorders, and cranial neuropathy. [1][2][3][4][5]14 Regardless, CVT is a rare manifestation. So far, only three cases of CVT in scrub typhus have been reported, all from India (Table 1).…”

“…10,11 Scrub typhus can have varied and peculiar neurological manifestations. [1][2][3][4][5]14 Amid those, CVT is an infrequent complication that is potentially treatable with prompt diagnosis. We propose that all cases of acute undifferentiated febrile illness with neurological manifestations from scrub-typhus endemic zones (like several parts of India) should be tested for the presence of Orientia tsutsugamushi infection (even in the absence of a pathognomonic "eschar") and treated accordingly.…”

“…1,2 The invasion by the pathogen damages endothelial integrity and cytokines released by these inflamed endothelial cells lead to fluid permeation, platelet and polymorph aggregation, and monocyte proliferation, further resulting in focal obliterative angiitis and microthrombi formation in the vicinity of the leptomeninges, brain parenchyma, and venous sinuses. [1][2][3][4][5][6] An eschar, which is often pathognomonic for scrub typhus infection found in intertriginous body portions as a bite mark of the vector (larval stage of trombiculid mite), is often absent and fails to provide an early clue to clinch the diagnosis. 7 Several central nervous system (CNS) infections can result in the development of cerebral venous sinus thrombosis (CVT).…”