Delusional Psychosis in a Patient of Scrub Typhus: A Case Report

Ahuja G, Sharma S and Jaswal S

Published on: 2024-04-24

Abstract

Scrub typhus is a tropical rickettsial infection caused by Orientia tsutsugamushi and transmitted by the bite of the mite larvae or chiggers. If left untreated or improperly treated, it can have fatal consequences [1]. The disease is known to be endemic to the geographically confined area of the Asia-Pacific region termed as the ‘tsutsugamushi triangle’, which covers South and Southeast Asia, Northern Australia, and the islands of the Indian and Pacific Oceans [2]. This disease is known to occur in diverse ecological settings in India with large numbers of cases being reported from Tamil Nadu, Andhra Pradesh, Karnataka, and Kerala in the South, Himachal Pradesh, Uttaranchal, Jammu, and Kashmir in the North, Meghalaya, Assam, and Nagaland in the North-East, West Bengal and Bihar in the East, and Maharashtra and Rajasthan in the West [3].

It is a systemic illness and can present as a vasculitis-like infection. After an incubation period of 6 to 21 days, symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy. An Escher at the site of chigger bite, regional lymphadenopathy, and a maculopapular rash may provide a clue to diagnosis. In severe cases splenomegaly, myocarditis, delirium, shock and death may occur [4].

Neurological manifestations of scrub typhus include meningitis, meningoencephalitis, cranial nerve involvement, cerebellitis, cerebral venous thrombosis, transverse myelitis, myoclonus, Parkinsonism, Guillain Barre Syndrome and neuroleptic malignant syndrome like presentation [4].

However, the availability of literature on the psychiatric manifestations of scrub typhus is limited to case reports mainly, which includes depression [5], visual hallucinations [6], and obsessive compulsive symptoms [7].

Keywords

Cerebral venous thrombosis; Scrub typhus

Case History

A 41 years married female with no past or family history of psychiatric illness and well-adjusted premorbid personality presented with chief complaints of reduced sleep and appetite, irritability and agitation, suspiciousness and pacing around for last 2 weeks in the psychiatry OPD. GPE and systemic examination were grossly within normal limits. On mental status examination hostility, severe psychomotor agitation, Irritable affect and delusion of persecution about other patients and attendants wanting to hurt her was noted. A probable diagnosis of acute and transient psychotic disorder (F23 according to ICD 10) [8] was made. In view of extreme agitation, she was given 5mg of Haloperidol and 50 mg of promethazine intramuscularly.

After this, patient remained unconscious and unresponsive to painful stimuli for next 2 days with stable vitals. She was assessed for her altered mental status. Neuroimaging was unremarkable. On reassessment of history, she had a history of fever 15 days back without any behavioral symptoms and was afebrile for last 12 days, for which she was evaluated and diagnosed with COVID 19 but during admission her RTPCR for COVID 19 was negative. As a part of routine protocol (as Scrub typhus is endemic in monsoon in our region) [9] she was tested for Scrub Typhus and her Ig M for scrub typhus turned Positive. Patient was treated on Doxycycline 100mg BD and she showed improvement. She was again assessed for psychiatric symptoms, but after treatment she did not show any psychiatric symptom.

Psychosis secondary to COVID 19 was also kept as possibility, but appeared less likely as patient improved after treatment and resolution of Scrub typhus infection and COVID 19 by RTPCR was also negative at time of screening.

Discussion

Though, occurrence of psychiatric manifestations in scrub typhus is not a commonly reported entity in literature but from our case it can be seen that failure in diagnosing scrub typhus can led to potentially fatal consequence.

Report a case of murine typhus (another rickettsial illness) infection presenting with acute psychosis as a part of delirium and mimicking DIC in an endemic area [10]. Ours is the first case report showing delusional psychosis in a patient of Scrub typhus. Thus patients with history of fever in endemic regions even without the presence of characteristic Escher and unremarkable neuroimaging, presenting primarily with behavioral disturbances, should undergo evaluation for Scrub Typhus. Scrub typhus should be kept as differential diagnosis especially in endemic areas as its treatment is an antibiotic course and prevents unnecessary antipsychotic exposure to the individual.

References

  1. Musa TH, Ahmad T, Wana MN, Li W, Musa HH, Sharun K, et al. ‘The epidemiology, diagnosis and management of scrub typhus disease in China’, Human Vaccines & Immunotherapeutics. 2021; 17: 3795-3805.
  2. Bonell A, Lubell Y, Newton PN, Crump JA, Paris DH. Estimating the burden of scrub typhus: A systematic review. PLoS Negl Trop Dis. 2017. 25; 11: e0005838.
  3. Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM. A review of the global epidemiology of scrub typhus. PLoS Negl Trop Dis. 2017; 3; 11: e0006062.
  4. Mahajan SK, Mahajan SK. Neuropsychiatric Manifestations of Scrub Typhus. J Neurosci Rural Pract. 2017; 8: 421-426.
  5. Wang YC, Chiu CH, Lin CL, Lee FY, Chang KH. Scrub typhus and depression: a nationwide cohort analysis. J Transl Med. 2018; 16: 333.
  6. Mahajan SK, Kaushik M, Raina R, Sharma RC, Thakur P, Bharat Sharma J. Scrub typhus with visual hallucinations. Tropical Doctor. 2015; 45: 146-147.
  7. Ripley HS. Neuropsychiatric observations on tsutsugamushi fever (scrub typhus). Archives of Neurology & Psychiatry. 1946; 56: 42-54.
  8. World Health Organization. International classification of diseases for mortality and morbidity statistics (11th Revision). 2018. 
  9. Mahajan SK, Rolain JM, Kashyap R, Bakshi D, Sharma V, Prasher BS, et al. Scrub typhus in Himalayas. Emerg Infect Dis. 2006; 12: 1590-1592.
  10. Pervaiz AM, Tariq R, Bangash SA, Lal Y. Murine Typhus Presenting with Acute Psychosis and Disseminated Intravascular Coagulation: A Case Report. Cureus. 2019; 11: e4450.