SARS-CoV-2 Induced Multisystem Inflammatory Syndrome in Children (MIS-C) with Seropositive Scrub Typhus: A Case Series.

Abstract

Statement of the problem: Pediatric patient with history of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was diagnosed with a serious condition called Multisystem Inflammatory Syndrome in Children (MIS-C). It is a post infectious excessive immune response differing from cytokine storm of SARS-CoV-2. MIS-C ranges from mild tosevere form, with multiorgan involvement viz, cardiac, gastrointestinal, renal, neurological, hematological etc.; and laboratory evidence of hyperinflammation. Scrub Typhus (ST), a mite borne rickettsial febrile zoonosis; has been reported in India and worldwide. It is caused by a gram-negative coccobacillus called Orientia tsutsugamushi and transmitted by the bite of chiggers, the infected larva of trombiculid mites (genus Leptotrombidium). ST present as a febrile illness with eschar and rash, but can manifest with a myriad of unusual presentations involving different organ system. Incidence of different organ involvement with rarity of association between these two conditions grew our interest on this case series.
 Methodology and Theoretical orientation: The study was conducted in the Pediatrics department of Malda Medical College and Hospital for a period of 6 months. All the subjects (age < 12 years) with complain of fever was evaluated for all tropical causes and among them the 3 child with
 
 a) Scrub Typhus IgM Ab Positive
 b) SARS-CoV-2 RTPCR Negative
 c) SARS-CoV-2 IgG antibody Positive
 d) MIS-C Positive (as per WHO’s definition) was included in the study. The 3 cases was clinically evaluated in details with signs, symptoms , laboratory parameters and treatment given.
 
 Findings: The CASE 1 and CASE 2 came with a neurological presentation on admission where as the CASE 3 presented with gastrointestinal one, fever being common in both. IV steroids, IVIg, Enoxaparin s/c were given to the patients but fever subsided with introduction of doxycycline after they became seropositive for scrub typhus. After thorough investigation it was found that both of them were positive for SARS-CoV-2 IgG antibody and Scrub Typhus IgM antibodywith features of MIS-C.
 Conclusion and Significance: Recently a seroprevalence study also reported a 5% co-infection of Scrub Typhus with seropositive MIS-C. The attribution of the co- infection in the Tsutsugamuschi Triangle with this clinical scenario and febrile presentation mimicking tropical diseases make this condition a circumstantial challenge. Pediatrician should be more vigilant while dealing with the febrile illness for early diagnosis and proper treatment of this condition.