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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 292-294  

Dengue and scrub typhus co-infection in children: Experience of a teaching hospital in an endemic area


1 Associate Professor, Department of Paediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Professor, Department of Paediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India
3 Professor and HOD, Department of Paediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission16-Nov-2021
Date of Decision31-Mar-2022
Date of Acceptance31-Jul-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Priya Jose
Department of Paediatrics, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_2052_21

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   Abstract 


Background: Dengue fever and scrub typhus are considered an endemic disease in the Indian subcontinent. The epidemiology and clinical presentations are complex and vary each year. Objective: The objective of this study was to estimate the prevalence of coinfection with scrub typhus in children diagnosed with dengue fever. Methods: A retrospective hospital-based, cross-sectional study was done in the Department of Pediatrics of a teaching hospital in Puducherry. All children (0–14 years) who had enzyme-linked immunosorbent assay (ELISA) reported scrub typhus among those diagnosed with dengue fever (NS1Ag or immunoglobulin M ELISA positivity) during 2012–2016. Medical records with incomplete data were excluded from the study. Odds ratio was calculated to find out the association of coinfections. An independent t-test was used to find out the statistical significance. P < 0.05 was considered statistically significant. Results: Atypical features of dengue were present in 250/318 (78.6%) children. Coinfections were seen in 62/318 (19.4%) children. Scrub typhus was the most common (n = 51/62, 82.2%). The chance of scrub typhus in a dengue serology-positive child is significant when the symptoms are atypical or protracted (OR– 2.6, P = 0.033). Conclusion: High index of suspicion should be present in endemic dengue and scrub typhus coinfection.

Keywords: Atypical features, coinfection, dengue fever, scrub typhus


How to cite this article:
Jose P, Rajan N, Kommu PP, Krishnan L. Dengue and scrub typhus co-infection in children: Experience of a teaching hospital in an endemic area. Indian J Public Health 2022;66:292-4

How to cite this URL:
Jose P, Rajan N, Kommu PP, Krishnan L. Dengue and scrub typhus co-infection in children: Experience of a teaching hospital in an endemic area. Indian J Public Health [serial online] 2022 [cited 2022 Sep 28];66:292-4. Available from: https://www.ijph.in/text.asp?2022/66/3/292/356599




   Introduction Top


Dengue fever is caused by single-stranded RNA viruses of the genus Flavivirus, transmitted by the bite of the infected Aedes mosquito, and is considered an endemic disease in the Indian subcontinent.[1] The epidemiology and clinical presentations are complex and vary each year.[2] A high index of suspicion for coinfection is needed, when the presentation is protracted, overlapping, and complex, irrespective of the result of serology.[2] There are reports available in the literature about the coinfections of dengue with enteric fever,[3] leptospirosis,[4] malaria,[5] hepatitis A,[6] chikungunya,[7] COVID,[8] scrub typhus,[9],[10] etc., We could not find many published reports on the coinfection of scrub typhus and dengue for the pediatric age group. The mortality rate for complicated scrub typhus and dengue fever in children is high. There can be capillary leakage, hemorrhage, hypotension, etc., that make the management complicated. Dengue fever needs precise monitoring for warning signs and severe dengue. Children with diagnosed scrub typhus need to be given doxycycline. We report a series of 51 children diagnosed with coinfection with scrub typhus in children with dengue fever.


   Methods Top


A retrospective hospital-based, cross-sectional study was done in the Department of Pediatrics of a teaching hospital in Puducherry, after getting clearance from the Institution Review Board and Institutional Ethics Committee. Data of children (0–14 years), admitted with dengue fever (NS1Ag or immunoglobulin M [IgM] enzyme-linked immunosorbent assay [ELISA] positivity), during January 2012–December 2016 was collected from the hospital medical records. The aim was to estimate the prevalence of coinfection with scrub typhus in children diagnosed with dengue fever. Inclusion criteria: All children (0–14 years) who had ELISA reported scrub typhus among those diagnosed with dengue fever (NS1Ag or IgM ELISA positivity) during 2012–2016. Exclusion criteria: Medical records with incomplete data were excluded from the study.

The case files of eligible patients were audited for demographic details, clinical features, course in the hospital, and diagnosis. The details of laboratory and radiological investigations, coinfections, and line of management were also noted. When the child presented with clinical manifestations as per the WHO criteria, it was considered typical manifestations of dengue. When there were any one or more atypical features, coinfections were suspected and appropriate investigations were sent.

Available data were collected using a predesigned pro forma and entered into a Microsoft Excel sheet. Analysis was done using the SPSS software 20 version. Descriptive statistics such as frequency and percentage were used for qualitative variables. The mean and standard deviation were used for quantitative variables. The odds ratio was calculated to find out the association of coinfections. An independent t-test was used to find out the statistical significance. P < 0.05 was considered statistically significant. The anonymized data collected were kept confidential and private.


   Results Top


A total of 1630 children were admitted with fever during the study period. Of these, 606/1630 (37.1%) were diagnosed to have dengue fever with positive dengue serology. Data on 88/606 (14.5%) were missing, and excluded from the study. Hence, a total of 518 patients were considered.

About 343/518 (66.3%) patients showed atypical features. Scrub serology was done on 92.7% (318/343) of children and hence 318 were included in the final analysis. Patient's file revealed that almost all of them were from rural areas with trees around (309/318, 97.2%), staying in kutcha house (262/318, 82.3%), water facility is only for 2 h a day for 278/318 children (87.4%), and mostly practiced open air defecation (115/318, 36.1%).

The common manifestations of dengue were fever (100%), myalgia (63, 19.8%), vomiting (142, 44.6%), retro-orbital pain (42, 13.2%), mucosal bleed (16, 5%) petechiae (42, 13.2%), hepatomegaly (111, 34.9%), pleural effusion (50, 15.7%), and hepatitis (60, 18.8%). The children with any one or more clinical features were considered atypical dengue.

Atypical features of dengue were present in 250/318 (78.6%) children. The most common atypical features were lymphadenopathy (51, 16%), splenomegaly (34, 10.6%), and seizure (8, 2.5%). Other atypical features were diarrhea, eschar, and respiratory distress, but the percentage of each was <2%.

Coinfections were seen in 62/318 (19.4%) children. Scrub typhus was the most common (n = 51/62, 82.2%) in our study. Other common infections enteric fever, bacterial (Escherichia coli and Klebsiella) sepsis, malaria, and respiratory infections were 18 (5.6%), 2 (0.006%), 2 (0.006%), and 11 (3.4%), respectively.

In a child diagnosed with dengue fever presenting with atypical features or with a protracted course, there is a significant chance of coinfection with scrub typhus in an endemic area for both infections (odds ratio – 2.3, P = 0.07).


   Discussion Top


India is endemic to dengue fever, and the morbidity and mortality are high. However, the notified number of dengue patients has come down, probably due to the varied presentations and presence of coinfections. Atypical features are being reported more commonly in children and several studies are available in the literature where more than half of the sample population have one or more atypical features.[11],[12],[13] Hepatitis was a common feature in all studies, but the percentages vary (40.6%, 3.2%, and 11.4% in the study done by Nimmagadde, Ahlawat, and Pothapregada, respectively[11],[12],[13]). The study done by Pothapregada also had lymphadenopathy (412%), splenomegaly (21.2%), and diarrhea (6.3%) similar to our study. The other atypical manifestations mentioned in their studies were portal hypertension, acalculous cholecystitis, appendicitis, Acute respiratory distress syndrome (ARDS), myocarditis, pericardial effusion, supraventricular tachycardia, myositis, acute kidney failure, hemophagocytic syndrome, and disseminated intravascular coagulation.[11],[12],[13] Hence, there should be high suspicion of dengue fever even if the presentation is atypical. Furthermore, a high index of suspicion for coinfection should be kept in these cases in endemic areas for other diseases.

When we evaluated for the cause of prolonged and protracted fever in children with dengue fever, 62/318 were with coinfections. Scrub typhus was the most common among that (n = 51/99, 51.5%). A literature search revealed that coinfection with dengue fever and scrub typhus is uncommon.

Scrub typhus caused by Orientia tsutsugamushi is also a common febrile illness in tropical countries. It is transmitted by a bite of trombiculid mite, the chigger. It is usually seen in people of low-income groups. However, a route of transmission through mites hidden inside the garments kept for drying under the sun which expands the spectrum to people with all socioeconomic statuses. Both diseases share some common features such as rash, thrombocytopenia, and hepatic dysfunction. Eschar is the pathognomonic feature of scrub typhus but is not present in all cases. There is only a limited awareness about the possibility of coinfections, especially when a firm primary diagnosis like dengue has been made, resulting in a high chance of missing the coinfection resulting in severe morbidity and mortality.[14] A 17-month-old was diagnosed in Kolkata to have coinfection of dengue fever and scrub typhus.[14] Another report of these two coinfections was of a 50-year-old adult patient.[10] There is a case report from Northern India and Nepal about the strong coinfection of dengue and scrub typhus in adults, masking the typical presentation of both diseases.[9] However, as our institution is located in an area endemic to dengue and scrub typhus, there should be a high index of suspicion of coinfection if there is a prolonged or protracted course of illness. There can be cross-reactivity between the antibodies of scrub typhus IgM and dengue IgM. Hence, there could be a high chance of having false positivity and hence Subhankar Mithra et al. developed a clinical score for distinguishing dengue fever and scrub typhus clinically.[15] However, in our study, 49 were diagnosed with Ns1Ag positivity and hence the possibility of false positivity is less.

Once coinfection is established vigilant monitoring of vitals, hematocrit, and platelets, cautious use of fluids and timely management with doxycycline should be initiated because the third space loss is a common complication of both conditions. Basheer et al. concluded that coinfection can have more tachycardia, hypotension, hypoalbuminemia, transaminitis, and prolonged activated thromboplastin time when compared to either infection.[14]

The overlapping clinical features of different illnesses could make the diagnosis difficult and delay treatment. Coinfection of dengue and scrub typhus should be considered when the clinical presentation, especially of dengue, is protracted. A high index of suspicion should be present in endemic areas such as Tamil Nadu and Puducherry for dengue and scrub typhus coinfection to facilitate appropriate antibiotics for scrub typhus at the earliest to prevent morbidity and mortality.

The strengths of the study are the large sample size, data backup from a single teaching hospital and the thought of coinfection in a resource-limited institution are the strengths of our study.

The limitation of our study is it is a retrospective study, children who were diagnosed with dengue fever in our hospital represent the community, dengue NS1Ag, dengue IgM, and scrub typhus IgM were done as and when suspected and hence false positivity or false negativity can be possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Kaur M, Singh K, Sidhu SK, Devi P, Kaur M, Soneja S, et al. Coinfection of Chikungunya and dengue viruses: A serological study from North Western Region of Punjab, India. J Lab Physicians 2018;10:443-7.  Back to cited text no. 7
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Nasomsong W, Luvira V, Phiboonbanakit D. Case report: Dengue and COVID-19 coinfection in Thailand. Am J Trop Med Hyg 2020;104:487-9.  Back to cited text no. 8
    
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Nimmagadda SS, Mahabala C, Boloor A, Raghuram PM, Nayak UA. Atypical manifestations of dengue fever (DF) – Where do we stand today? J Clin Diagn Res 2014;8:71-3.  Back to cited text no. 11
    
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Ahlawat RS, Kalra T. Atypical manifestations of dengue fever in a recent dengue outbreak. Ann Trop Med Public Health 2017;10:1448.  Back to cited text no. 12
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Pothapregada S, Kamalakannan B, Thulasingam M. Clinical profile of atypical manifestations of dengue fever. Indian J Pediatr 2016;83:493-9.  Back to cited text no. 13
    
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Roy S, Chakrabartty S. Scrub typhus and dengue coinfection in a 17-month-old child. Indian J Case Rep 2017;3:134-6.  Back to cited text no. 14
    
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Mitra S, Gautam I, Jambugulam M, Abhilash KP, Jayaseeelan V. Clinical score to differentiate scrub typhus and dengue: A tool to differentiate scrub typhus and dengue. J Glob Infect Dis 2017;9:12-7.  Back to cited text no. 15
    




 

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