Abstract
Rickettsial infections are re-emerging in the Indian subcontinent, especially among children. Understanding geographical and clinical epidemiology will facilitate early diagnosis and management. Children aged <18yrs hospitalized with clinically-diagnosed rickettsial fever were reviewed retrospectively. Frequency distributions and odds ratios were calculated from tabulated data. Among 262 children hospitalized between January 2008-December 2012, median age was five years, and 61% were male children. Hospitalized cases increased steadily every year, with the highest burden (74%) occurring between September and January each year. Mean duration of fever was 11.5 days. Rash was present in 54.2% (142/262) of children, with 37.0% involving palms and soles. Prevalence of malnutrition was high (45% of children were underweight and 28% had stunting). Retinal vasculitis was seen in 13.7% (36/262), and the risk appeared higher in females. Severe complications were seen in 29% (purpura fulminans, 7.6%; meningitis and meningoencephalitis, 28%; septic shock, 1.9%; acute respiratory distress syndrome, 1.1%). Complications were more likely to occur in anemic children. Positive Weil-Felix test results (titers ≥1:160) were seen in 70% of cases. Elevated OX-K titers suggestive of scrub typhus were seen in 80% (147/184). Patients were treated with chloramphenicol (32%) or doxycycline (68%). Overall mortality among hospitalised children was 1.9%. This five-year analysis from southern India shows a high burden and increasing trend of rickettsial infections among children. The occurrence of retinal vasculitis and a high rate of severe complications draw attention to the need for early diagnosis and management of these infections.
Highlights
Rickettsial infections are re-emerging in the Indian subcontinent, especially among children
A total of 262 children were diagnosed as having rickettsial infection over the five-year study period
Rash was present in 54.2% of children and was mostly macular-papular in nature
Summary
Rickettsial infections are re-emerging in the Indian subcontinent, especially among children. Rickettsial infections are distributed throughout the world and are re-emerging in the Indian subcontinent, especially among children. Multiple factors contribute to the gross under-diagnosis of rickettsial infections; these include the relatively non-specific disease presentation, low index of suspicion, and lack of awareness about its re-emergence [3,11,12,13]. The lack of proper clinical diagnostic techniques in low-income settings such as India further contributes to a delay in starting treatment This is mainly due to the fact that the only test available is the Weil-Felix test, which does not lead to a definitive diagnosis. The immunofluorescence assay (IFA) is the gold standard for diagnosis, but it is not available in India [3] These diagnostic deficiencies result in physicians relying on clinical suspicion alone to begin treatment, and point to a need for the development of newer, cost-effective diagnostic assays
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