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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 29-31

A rare case of scrub typhus with complete heart block


1 Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, Odisha, India
2 Department of Cardiology, Apollo Hospitals, Bhubaneswar, Odisha, India

Date of Web Publication2-Apr-2018

Correspondence Address:
Sharmili Sinha
Department of Critical Care Medicine, Apollo Hospitals, Old Sainik School Road, Samantapuri, Bhubaneswar - 751 005, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_42_17

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  Abstract 

Scrub typhus is a tropical fever prevalent in South East Asia. It is a multisystem disease which can vary widely in clinical manifestations from mild generalized symptoms to multiorgan dysfunction syndrome. Myocarditis is a known complication which can present with tachycardia, heart failure, and very rarely heart blocks. We report a case of complete heart block due to scrub typhus case which was treated successfully at our center.

Keywords: Heart block, myocarditis, scrub typhus


How to cite this article:
Sinha S, Pati J, Das B. A rare case of scrub typhus with complete heart block. Apollo Med 2018;15:29-31

How to cite this URL:
Sinha S, Pati J, Das B. A rare case of scrub typhus with complete heart block. Apollo Med [serial online] 2018 [cited 2021 Sep 24];15:29-31. Available from: https://www.apollomedicine.org/text.asp?2018/15/1/29/229063


  Introduction Top


Scrub typhus is a tropical fever prevalent in South East Asia. It is a disease which can vary widely in clinical manifestations from mild generalized symptoms to multiorgan dysfunction syndrome (MODS) and thus can closely mimic bacterial sepsis. It can virtually affect all organ systems such as nervous system, respiratory, cardiovascular, renal, hepatic, and musculoskeletal system. The cardiovascular complications include myocarditis, heart failure, tachyarrhythmias, and first-degree heart block. The incidence of complete heart block (CHB) is very rare in such cases. We found one report of CHB in a case of scrub typhus from Thailand in literature search. We report a patient with CHB due to scrub typhus who was successfully managed in our center. We believe this is the first report of such a case in India.


  Case Report Top


A 68-year-old male known smoker, hypertensive presented with complaints of intermittent high-grade fever with chills for 12 days associated with throat pain and breathlessness for 3 days. He was treated with antimalarial therapy initially outside. However, in view of nonresolving fever and 1 episode of severe hypoglycemia, he was shifted to our center for further management. On admission to emergency department, he had altered sensorium and hypotension (blood pressure 88/50 mmHg). Respiratory rate was 24/min with bronchospasm. There was mild epigastric tenderness. He was drowsy but maintaining airway with good cough reflex. ABG showed metabolic acidosis (pH 7.36, HCO3 19 mmol/L, BE – 6.3 mmol/L, PCO2 33.1 mmHg, lactate 5.25 mmol/L). He was resuscitated with fluids and started on vasopressors. He was started on meropenem, teicoplanin and doxycycline and antimalarial agents empirically after sending blood and urine culture along with tests for tropical fever. Initial laboratory parameters showed normal leukocyte count, deranged liver, and renal function with IgM antibodies positive for scrub typhus [Table 1]. All cultures were found negative. Then, azithromycin was added and only doxycycline was continued. He had dark skin and no visible eschars. His sensorium, hemodynamic status, and hepatic and renal parameters improved and was off vasopressors in 48 h. His initial electrocardiogram (ECG) was normal [Figure 1]. On day 4, he developed bradyarrhythmia down to heart rate of 30/min. ECG and Holter monitor showed CHB [Figure 2] and [Figure 3].
Table 1: Blood investigations

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Figure 1: Initial electrocardiogram

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Figure 2: Long pause in electrocardiogram

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Figure 3: Central monitor with long pause

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There was no episode of hypoxia. His potassium was normal, and he was not any heart rate-controlling drugs. It was managed with atropine and then a temporary pacemaker (TPI) was inserted through right femoral route. He had pacemaker-dependent cardiac rhythm. He required intermittent noninvasive ventilator (NIV) support for hypercapnic respiratory failure (pH 7.308, PCO2 48.6 mmHg, BE – 1.8 mmol/L). He was drowsy in-between with rise in CO2 with good oxygen saturation. There was a brief episode (30 s) of asystole on day 4 of TPI. During check process under fluoroscopy, it was observed that there was downward displacement of pacemaker lead during inspiration most likely leading to long pause and brief syncopes. This might have been responsible for drowsiness. The first TPI was removed, and a new one was inserted through left femoral route. After total 6 days of TPI, a decision was made for a permanent pacemaker (PPM). Next day, he had low-grade fever (max 100 degF) with rising total leukocyte count (14,000/ml). Serum procalcitonin was found normal (<0.5 ng/ml) twice 24 h apart, and therefore, decision was made to proceed with PPM. A single-chamber, VVIR (Ventricle paced Ventricle sensed Response to sensing Inhibited Rate modulation) magnetic resonance imaging-compatible PPM was implanted after 8 days of TPI. His coronary angiogram was normal. Next day, he became fully conscious with diminishing NIV requirement. Post-PPM ECG was fine [Figure 4].
Figure 4: Electrocardiogram after permanent pacemaker

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He was shifted to ward on day 11 but continued to have intermittent fever (max 102 degF) with mild tachypnea. Doxycycline was continued for total 14 days. He was discharged in stable condition on day 18. At follow-up after 2 weeks, he is afebrile and doing well.


  Discussion Top


Scrub typhus is known to be associated with multiorgan involvement. Cardiac manifestations commonly include tachycardia, heart failure, and myocarditis. Myocarditis usually manifests as tachycardia and heart failure and contributes to mild-to-moderate respiratory distress. There has been a case report of fulminant myocarditis.[1] Rarely, CHB has been described as a complication. One case has been reported so far from North Thailand which was cured after intravenous chloramphenicol.[2] Another case series from Shandong province, China describes 15 patients with ECG changes of which only 4 patients (26.7%) had partial to CHB.[3] Our case is the first one to be reported from India with CHB due to scrub typhus. In this instance, the bradycardia and CHB developed on day 4 when he was already on dual coverage for scrub typhus, i.e., doxycycline and azithromycin. The heart block did not improve despite ongoing treatment after 6 days of TPI and he was completely dependent on it. He was not on any rate control agents. His potassium was in the normal range all through (3.8–5.5 mmol/L). Coronary cause for heart block was excluded as conoraries were found to be normal in angiogram. The heart block could have been due to myocarditis involving the conduction pathways. He had antibody titers 1.7 ng/ml, about 3 times of the cutoff value (0.5 ng/ml). He had high-grade fever more than 101° F for 15 days. Cardiac biopsy was not done due to his dependence on TPI which was at risk of displacement. Acute respiratory distress syndrome, myocarditis, and acute kidney injury are known to be associated with high mortality. Average mortality remains 7% in both children and adults.[4],[5] None of studies have demonstrated any association between the duration of fever, serum titer of antibodies, and complications associated with higher mortality risk.


  Conclusion Top


Scrub typhus should be strongly suspected in cases of nonresolving fever with MODS in India. Myocarditis is a known complication of scrub typhus. Very rarely, this can lead to permanent CHB requiring pacemaker.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sittiwangkul R, Pongprot Y, Silviliarat S, Oberdorfer P, Jittamala P, Sirisanthana V, et al. Acute fulminant myocarditis in scrub typhus. Ann Trop Paediatr 2008;28:149-54.  Back to cited text no. 1
    
2.
Thipmontree W, Tantibhedhyangkul W, Silpasakorn S, Wongsawat E, Waywa D, Suputtamongkol Y, et al. Scrub typhus in northeastern Thailand: Eschar distribution, abnormal electrocardiographic findings, and predictors of fatal outcome. Am J Trop Med Hyg 2016;95:769-73.  Back to cited text no. 2
    
3.
Zhang M, Zhao ZT, Wang XJ, Li Z, Ding L, Ding SJ, et al. Scrub typhus: Surveillance, clinical profile and diagnostic issues in Shandong, China. Am J Trop Med Hyg 2012;87:1099-104.  Back to cited text no. 3
    
4.
Taylor AJ, Paris DH, Newton PN. A systematic review of mortality from untreated scrub typhus (Orientia tsutsugamushi). PLoS Negl Trop Dis 2015;9:e0003971.  Back to cited text no. 4
    
5.
Kumar Bhat N, Dhar M, Mittal G, Shirazi N, Rawat A, Prakash Kalra B, et al. Scrub typhus in children at a tertiary hospital in North India: Clinical profile and complications. Iran J Pediatr 2014;24:387-92.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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