Journal of Clinical and Diagnostic Research. 2023 Feb, Vol-17(2): SD01-SD04 1 1 DOI: 10.7860/JCDR/2023/59478.17452 Case Report Paediatrics Section Doxycycline-resistant Scrub Typhus in a Syndromic Child CASE REPORT A 10-year-old female child was bought to the hospital with complaints of fever for six days, cough for three days, loose stools for two days, and vomiting for one day duration. The fever was low grade, intermittent, relieved by medications, and not associated with chills and rigors lasting for six days. The child had a productive cough, sputum was mucoid in consistency, not associated with any nocturnal or diurnal variations and non blood stained sputum.The child had loose stools, watery in consistency, not foul smelling and not blood stained. She had a history of one episode of vomiting which was non projectile, consisted of food particles with no haematemesis. There was no history of rash, sore throat, dysuria, ear pain or ear discharge. The child was operated for inguinal hernia at 45 days of age. The antenatal history was uneventful. The child was born of full term normal delivery, did not cry immediately after birth and was kept in the Neonatal Intensive Care Unit (NICU) for an hour. There was history of a mild developmental delay. She was immunised to date and was on a normal diet. She was born of second-degree consanguineous marriage. There was no history of contact with open tuberculosis. There was no history of travel. There was history of infestation of rodents and ticks in the locality of residence but there was no known history of bites. She was on Doxycycline 100 mg 1-0-1/2 for one day which was started by a private practitioner, suspecting scrub typhus due to the presence of the eschar. On examination, she weighed 35 kg (75 th percentile for age and sex), and her height was 147cm (95 th percentile), her head circumference was 57 cm and chest circumference was 64 cm. She had a bell- shaped chest, with frontal bossing, depressed bridge of nose, hypertelorism, and squint. She had Marphanoid features. Her body temperature was 101.7 o C, Pulse Rate (PR) was 104 beats per minute, Respiratory Rate (RR) 29/my, Blood Pressure (BP) was 100/80 mm Hg. She was anaemic. No jaundice, cyanosis, clubbing, pedal oedema and lymphadenopathy were observed. There was an eschar 2 cm by 1.5 cm in the right inguinal region [Table/Fig-1,2]. On systemic examination, S1 S2 and bilateral normal vesicular breath sounds heard. Abdomen showed no hepatosplenomegaly and CNS examination showed no focal neurologic deficits. Investigations showed a normal leukocyte count and DLC, microcytic hypochromic anaemia, thrombocytopenia, hyponatremia. Liver enzymes were elevated and other liver function tests were normal. Urine routine examination was normal and culture/sensitivity showed no growth. Stool examination was normal and it showed no growth. Widal test, done on the eighth day of fever, was negative. Blood PRIYA MARGARET 1 , S RAMITHA ENAKSHI KUMAR 2 , V REVATHI 3 Keywords: Azithromycin, Hyponatremia, Immunoglobulin M ABSTRACT Scrub Typhus, a human febrile illness caused by Orientia tsutsugamushi, is common in Asia and infects persons those visiting the endemic areas. Scrub typhus is a zoonotic infection. It is transmitted by a trombiculid mite which introduces the bacteria by its bite. Scrub typhus is associated with maculopapular rashes and local and/or generalised lymphadenopathy.It is characterised by eschar at the site of the bite. A child with doxycycline-resistant scrub typhus is being presented here. A 10-year-old female child was bought to the hospital with complaints of fever for six days, cough for three days, loose stools for two days, and vomiting for one day duration. S1 and S2 sounds were heard while bilateral vesicular breath sounds were normal. There was no hepatosplenomegaly and Central Nervous System (CNS) examination showed no focal neurologic deficits. Investigations showed a normal leukocyte count and Differential Leucocyte Count (DLC), microcytic hypochromic anaemia, thrombocytopenia, hyponatremia, and elevated liver enzymes. Scrub Immunoglobulin M (IgM) was positive. Chest radiograph showed a bell-shaped chest with vertical straightening of ribs. The child was started on intravenous (i.v.) fluids, Doxycycline 4 mg/kg, and paracetamol. The child continued to spike fever at day 6 of Doxycycline and hence was started on Azithromycin 10 mg/kg, following which the fever subsided and the child was discharged. [Table/Fig-1]: Eschar. [Table/Fig-2]: Hypertelorism (line), frontal bossing (arrow).