Scrub Typhus (Tsutsugamushi Disease)

 

Ms. Indu Rathore

Assistant Professor, Murari Lal Memorial School and College of Nursing, Village- Nagali, P.O. Oachghat

Solan (HP) - 173223

 

ABSTRACT:

Scrub typhus is caused by the bacteria of the rickettsiaceae family, which spreads through mites in human beings. Scrub typhus derived its name from the two terms "scrub" means "small plant or bushes" and "typhus" means "fever with stupor". Scrub typhus is also famous as a Tsutsugamushi Disease (Orientia tsutsugamushi bacteria). By the bite of chigger mite, the bacteria is transferred into the human body. The common sign/symptoms of scrub typhus are sudden fever (above 104꠶F), severe headache, pain in the muscles and body, coughing, swelling of lymph glands in various parts of the body, vomiting, diarrhea etc. There is a formation of scar at the site of mite bite. But the scar may not be present in all the cases. Weil- Felix test is the cheapest and easily available for the diagnosis of scrub typhus. The scrub typhus can be treated effectively with antibiotics such as Doxycycline or Azithromycin. Preventive measures include the prevention from mite bite and the destruction of mites through insecticides. Nurses working in the community area and other health workers like ANMs, ASHAs and Anganwadi Workers have ample opportunities for the prevention and management of patient with scrub typhus.

 

 

 

INTRODUCTION:

Scrub typhus is caused by the bacteria of the rickettsiaceae family, which spreads through mites in human beings.^1-2  Scrub typhus derived its name from the two terms "scrub" means "small plant or bushes" and "typhus" means "fever with stupor". It is also famous as "Tsutsugamushi disease", because scrub typhus is caused by the infection of Orientia tsutsugamushi bacteria. The term "tsutsuga" means "dangerous and small" and "mushi" means "insect".³

 

Firstly, it was found in Japan in 1899. During World War II, the disease affected thousands of soldiers. Every year this disease affects more than 1 million people all around the world. In India, the states affected by scrub typhus are- Himachal Pradesh, Jammu and Kashmir, Uttrakhand, Bihar, Meghalaya, West Bengal, Rajasthan, Maharashtra, Tamil Nadu, Karnataka and Kerala etc.^1,4

 

Life cycle of the mite:

The life cycle of the mite includes four stages: eggs, larva, nymph and adult. Only the larval stage (chigger) can spread the disease to human beings and other animals such as rats and mice. The other stages do not bite human beings and other animals⁴.

 

 

Mode of transmission:

Orientia tsutsugamushi is present in the salivary glands of the chigger mite. By the bite of chigger mite, it is transferred into the human body.² As the size of mite is very small (0.2- 0.4mm),the mite cannot be seen by the naked eyes.⁴ There is no pain at the site of mite bite, hence the disease is not diagnosed on time. The scrub typhus does not spread directly from one person to another.¹

 

People at risk:

People engaged in agriculture and horticulture activities and those who travel in forests and gardens for recreation etc. may be affected with scrub typhus.

 

Environmental Factors:

Rainy season or cold weather, lands after clearing of forests, riverbanks, grasslands, seashore, rice fields and semi-desert areas favors the transmission of scrub typhus.

 

Incubation period:

The incubation period of scrub typhus is about 5 -20 days (mean 10-12 days).⁴

 

Clinical manifestations:

The common sign/symptoms of scrub typhus are sudden fever (above 104꠶F),severe headache, pain in the muscles and body, difficulty in breathing, coughing, swelling of lymph glands in various parts of the body, enlargement of liver and spleen, vomiting, diarrhea, stomach ache, photophobia etc. There is the formation of a painless papule on the skin at the site of mite bite, after healing it becomes a black spot (scar) and looks like a cigarette burn marks. But scar may not be present in all the cases. The rashes emerge firstly on the trunk and then on extremities.⁵

 

Complications:

Complications that affects are pneumonia, myocarditis, meningoencephalitis, Acute Respiratory Distress Syndrome (ARDS), hepatic failure, renal failure, pleural effusion, GI Bleeding, shock etc.^3,5

 

Laboratory Diagnosis:

Lab investigations that help to diagnose the scrub typhus are Weil- Felix test (Cheapest, easily available), Complement-fixation Test, Indirect Immunofluorescence Antibody (gold standard), Qualitative enzyme-linked immunosorbent assay (ELISA), Polymerase Chain Reaction (PCR) and bacterial culture. Other supportive investigations include -Blood counts, Liver Function Tests, Renal Function Tests, Chest X-ray, Ultrasound abdomen etc.³

 

 

 

Treatment:

The scrub typhus can be treated effectively with following antibiotics-

Tablet. Doxycycline 200mg/day for individuals above 45kg weight (7days) or Tablet. Azithromycin 500mg/day (5days) If a patient is intolerant to Doxycycline, then he is given Azithromycin. Do not give Doxycycline to pregnant mothers or children under 8 years of age. Doxycycline is taken with adequate water during and after consumption of food. Tetracycline group of drug may cause discoloration of teeth, incomplete formation of teeth enamel, retarded physical development in children.^5,6

 

Prophylaxis:

In special circumstances, for the prevention of disease, a single oral dose of chloramphenicol or tetracycline drug is given in every 5 days with 5 days of non- treatment intervals for 35 days.⁶

 

Vaccine:

No vaccine is available to prevent scrub typhus till date.

 

Prevention:

People at risk should not go to places where the scrub typhus mite is found. They should wear high heel shoes and full-size clothes when going outside for work. There should be application of mitecides (permethrin and benzyl benzoate) in clothes and blankets. People engaged in agricultural activities should use mite repellant cream on their body. They must cover their full body, especially foot, legs and hands with full size clothes. After working outside, they should take a bath with soap and water as soon as possible.

 

People should avoid sitting and sleeping on the grass. They should use mats while sitting on the ground. People should not allow small bushes and grass to grow around their houses. There should be the control the rodents (rat and mice) near the human dwelling places. People should use mitecides (e.g. Lindane etc.) on the ground or bushes to destroy the mites.^1,3,6

 

Role of the community health nurse in care of patient with scrub typhus:

The community health nurses have the key role in prevention and care of the patient with scrub typhus. Any type of fever case during the rainy season must be immediately referred to medical officer at the health centre. Maintain a peaceful, well ventilated, warm and quiet environment around the patient to promote sleep and relaxation. All the necessary articles such as medicines, towels, water etc. should be kept in the patient room. Give sponging with lukewarm water to manage the fever. Provide adequate bed rest and medicines as per doctor's advice to relieve headache and body pain. Steam inhalations should be given to relieve nasal and chest congestion. Provide ORS and plenty of fluids in case of dehydration due to diarrhea and vomiting. Calamine lotion should be used for skin rashes. The scar does not need any dressing as it heals by itself. Advise the patient for daily bath and to wear clean cotton clothes to maintain physical cleanliness. Provide patient with easily digestible, tasty and calorie rich diet. Offer more and more beverages such as lemon and coconut water, fruit juice, vegetable soup. Provide small and frequent diet for the patient.

 

Monitor the patient for the signs of complications such as hypotension, breathlessness, neck stiffness, seizures, altered sensorium, jaundice etc. and make urgent referral. Use pillows under the patient’s head and loosen the tight clothes from patient’s neck in the case of breathing difficulty. In severe bed ridden patients provide back massage, clean, dry and wrinkle less bed sheet. Assist the patient to change their position time to time.

 

Nurses working in the community area and other health workers like ANMs, ASHAs and Anganwadi Workers have ample opportunities for the prevention and management of patient with scrub typhus. They can create awareness regarding scrub typhus, its prevention and management in endemic areas in pre-monsoon months (June-July).^7,8

 

CONCLUSION:

Scrub typhus is a re-emerging infectious disease of India. A holistic health care approach will help to meet the needs of a challenging situation.

 

ACKNOWLEDGEMENT:

The author would like to thank the vice –principal, faculty members and students of Murari Lal Memorial School and College of Nursing, Solan (HP) for their help in writing the present review.

 

REFERENCES:

1.       Park. K. Parks text book of Preventive and Social Medicine. 23rd edition: M/s Banarsidas Bhanot: 2015.p. 299-300

2.       Mahajan SK. Scrub Typhus. Journal of the Association of Physicians of India. [Internet].2005 Nov [cited 2016 Dec 11]; 53: 954-958. Available from: http:// www. japi.org/november2005/R-954.pdf

3.       Ramasubramanian V, Senthur Nambi P. Scrub Typhus [Internet] [cited 2016 Dec 11]; 19-22. Available from: http://www.apiindia.org/medicine_update_2013/chap06.pdf

4.       WHO. Frequently Asked Questions Scrub Typhus. [Internet] 2013 [cited 2016 Dec 11]. Available from: http://www.searo.who.int/entity/ emerging_diseases /CDS_faq_ Scrub_Typhus.pdf.

5.       National Centre for Disease Control. DGHS. GOI. CD Alert. Scrub Typhus & Other Rickettsioses. [Internet] 2009 [cited 2016 Dec 11]. Available from: http://www.ncdc.gov. in/ writereaddata/linkimages/May%20June-20098604739980.pdf

6.       DHR-ICMR. Diagnosis and management of rickettsial diseases in India. [Internet] 2015 [cited 2016 Dec 11]. Available from:http://www.icmr.nic.in/guide/DHR ICMR%20 Guidelines% 20 on % 20 Ricketesia l% 20 Diseases. pdf

7.       Director Health Services. Himachal Pradesh. Guidelines for the Management of Scrub Typhus [Internet] [cited 2016 Dec 11]. Available from: http://www.himachal.nic.in/WriteReadData/l892s/19_l892s/ 1442477 304.pdf

8.       Worden I. Scrub Typhus Fever. Nursing of scrub typhus patients in a combat zone. The American Journal of Nursing [Internet].1944 Oct [cited 2016 Dec 11];44(10): 942-944. Available from: http://journals.lww.com/ajnonline /Citation/1944/10000/Scrub _ Typhus_Fever__Nursing_of_scrub_typhus.13.aspx

 

 

 

 

 

Received on 16.05.2017       Modified on 15.07.2017

Accepted on 20.09.2017      ©A&V Publications All right reserved