The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus

Abstract

Background and study aims: Scrub typhus is an acute febrile illness caused by Rickettsia tsutsugamushi-induced vasculitis, which is common in Asia and the Pacific islands and is sometimes encountered in Western countries because of increased travel and economic changes spurred by world globalization. Skin rash and eschar are typical physical findings on the trunk and extremities, but endoscopic mucosal changes have not been described in the gastrointestinal tract until now. We aimed to describe different endoscopic characteristics of the gastrointestinal manifestation of scrub typhus, to ascertain the necessity for endoscopy, and to determine correlations between the degrees of endoscopic lesion and clinical severity, including cutaneous manifestation.

Patients and methods: Between January 1993 and October 1998, out of 256 scrub typhus patients, we applied esophagogastroduodenoscopy to 58 patients who complained of gastrointestinal symptoms but had no past history of these symptoms. We categorized clinical severity into four grades according to the degree of six clinical indicators of systemic complications, and endoscopic findings were graded from I to IV (I, normal, nonspecific hyperemia; II, distinct hyperemia, petechiae, purpura; II, superficial hemorrhage, erosion; IV, ulcer, active bleeding).

Results: Endoscopic findings of scrub typhus were characterized by petechiae, superficial hemorrhage, erosion, ulcers, and vascular bleeding (grade I, 14 patients; grade II, 11 patients; grade III, 16 patients; grade IV, 17 patients). In 83.3% of patients there was multiple occurrence of lesions without any predilection sites. Clinical severity was graded (grade I, 7 patients; grade II, 23 patients; grade III, 22 patients; grade IV, 6 patients). There was a correlation between clinical severity and endoscopic findings (P < 0.01). The grade of lesion was high in patients with cutaneous lesions (r(s) 0.359, P < 0.01). In two cases of gastric vascular bleeding, complete hemostasis was achieved by endoscopic hemoclipping.

Conclusions: The major endoscopic features that can develop in scrub typhus are superficial mucosal hemorrhage, multiple erosions and ulcers without any predilection sites, and unusual vascular bleeding. The endoscopic features are related to cutaneous lesions and severity of the disease. Endoscopy is useful for diagnosis and management of gastrointestinal vasculitis related to scrub typhus.