Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Apr 10;19(1):102.
doi: 10.1186/s12887-019-1475-x.

Misdiagnosis of scrub typhus complicated by hemophagocytic syndrome

Miaomiao Lin  1 , Airong Huang  1 , Xiang Zheng  1 , Lisha Ge  1 , Shijun He  2
Affiliations

Misdiagnosis of scrub typhus complicated by hemophagocytic syndrome

Miaomiao Lin et al. BMC Pediatr. .

Abstract

Background: This study sought to analyze the cases of clinical misdiagnosis of scrub typhus complicated by hemophagocytic syndrome.

Methods: We retrospectively reviewed the medical records for diagnoses, clinical course, chest X-ray findings, laboratory data, and antibiotic therapy.

Results: All nine patients were misdiagnosed at the outpatient department between 07/2009 and 07/2017. They were diagnosed with septicemia and hemophagocytic syndrome, sepsis and hemophagocytic syndrome, severe infection, hepatitis and hemophagocytic syndrome, or upper respiratory tract infection. Among the nine patients, hepatic function examination showed decreased albumin and elevated C-reactive protein levels in all patients; alanine aminotransferase was increased and platelets were decreased in eight patients. Weil-Felix reaction was positive in three of nine patients. Indirect immunofluorescence demonstrated positive IgM antibody and EB virus-IgM in all nine patients; Mycoplasma pneumoniae antibody was positive in seven patients. All nine patients underwent chest computed tomography; no abnormality was found in two patients. Patch shadow with increased density was found in seven patients, including four patients with right pleural effusion and two with bilateral pleural effusion. Bone marrow biopsy was performed in all nine patients and hemophagocytic cells were seen. The nine misdiagnosed cases were given multiple broad-spectrum antibiotics either successively or concomitantly before and after admission, but no effective antibiotics against Orientis tsutsugamushi were applied. After diagnosis was corrected to scrub typhus, five patients were switched to chloramphenicol and dexamethasone, two patients were given azithromycin and dexamethasone, and two patients were treated with chloramphenicol. Body temperature returned to normal within 2-3 days and the children were quickly relieved from their condition.

Conclusion: Hemophagocytic syndrome may be the presenting clinical feature of scrub typhus and initially mask the disease. Initial misdiagnosis is common and includes septicemia and hemophagocytic syndrome. The eschar is a useful diagnostic clue and febrile patients without any localizing signs should be thoroughly examined for its presence.

Keywords: Eschar; Hemophagocytic syndrome; Misdiagnosis; Scrub typhus.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate

The study approve by the Ethics Committees of the Second Affiliated Hospital of Wenzhou Medical University (L-2018-34). All participants’ legal guardian provided written informed consent.

Consent for publication

All participants’ legal guardian agreed to publish patients’ data and pictures.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Eschar on the left shoulder
Fig. 2
Fig. 2
Ulcers in the fold of anterior cervical skin
Fig. 3
Fig. 3
Two lung patch shadows with pleural effusion
Fig. 4
Fig. 4
Bone marrow macrophage phagocytosis
See this image and copyright information in PMC

References

    1. Zhang Y, Wu G, Deng X, Wang Z, Cao G. Relationship between geographical features and epidemic characteristics of tsutsugamushi disease in southeast coastal areas. Chin public health. 2010;26:174–5.
    1. Kawamura A. Tsutsugamushi disease. Japan: University of Tokyo Press; 2010.
    1. Jeong YJ, Kim S, Wook YD, Lee JW, Kim KI, et al. Scrub typhus: clinical, pathologic, and imaging findings. Radiographics. 2007;27(1):161–172. doi: 10.1148/rg.271065074. - DOI - PubMed
    1. Kim DM, Won KJ, Park CY, Yu KD, Kim HS, et al. Distribution of eschars on the body of scrub typhus patients: a prospective study. Am J Trop Med Hyg. 2007;76(5):806–809. doi: 10.4269/ajtmh.2007.76.806. - DOI - PubMed
    1. Branch HGoCMAP. Hematology Group of Chinese Medical Association Pediatrics Branch. Advice on diagnosis and treatment of hemophagocytic lymphohistiocytosis. Chin J Paediatr. 2012;50.