Correspondence

Scrub Typhus after a Trip to Vietnam

N Engl J Med 1997; 336:1613-1614May 29, 1997

Article

To the Editor:

In addition to malaria, leptospirosis, typhoid fever, amebiasis, and viral infections, the rickettsial diseases are an important consideration in the differential diagnosis of febrile infection in travelers returning from tropical Asia. Rickettsia tsutsugamushi is transmitted by chiggers of the genus leptotrombidium and causes scrub typhus, an illness reported in Southeast Asia, the former Soviet Union, Japan, and Australia. New foci of scrub typhus have recently been described in Australia, Japan, Thailand, and Korea.1 We report here an instance of this disease in a traveler to Vietnam since the end of the Vietnam war in 1972.

The patient, a 21-year-old man, had traveled across Vietnam from north to south. On his return to France, he presented with high fever, a thoracic maculopapular rash, polyadenopathy, and a black eschar on the left leg. He had mild hepatitis and thrombocytopenia. He was treated with doxycycline (200 mg per day) and became afebrile on the fifth day. His serum tested positive for scrub typhus by immunofluorescence (strain Gilliam, IgG 1:256 and IgM 1:1024; strain Kato, IgG 1:128 and IgM 0; strain Karp, IgG and IgM negative). The eschar was sampled after five days of treatment and R. tsutsugamushi–specific nested polymerase-chain-reaction amplification was performed from a 56-kd-protein–encoding gene as described by Furuya et al.2 Sequence determinations were performed, and the Gilliam original sequence was identified.

Scrub typhus became well known during the Vietnam war, when it was diagnosed in 10 percent of febrile American soldiers.3 Since then the disease has been studied little in Vietnam, but this case proves that scrub typhus persists there. Vietnam has become more accessible to tourists, and physicians should be aware of this disease in people returning from there. Maculopapular rash and eschar are usually considered clues for diagnosis of a rickettsial infection, but in scrub typhus they are present only in 67 percent and 50 percent of the patients, respectively. The disease should be considered in patients with fever and polyadenopathy (present in 85 percent of cases). The diagnosis is critical. Defervescence after treatment with doxycycline and chloramphenicol was once used as a diagnostic test for R. tsutsugamushi infection, but it is now less reliable, because there are resistant organisms.4

Marie Marthe Thiebaut, M.D.
François Bricaire, M.D.
Groupe Hospitalier, 75665 Paris, France

Didier Raoult, M.D., Ph.D.
Université de la Mediterranée, 13385 Marseilles CEDEX 05, France

4 References

1. 1

   Tarasevich I. Scrub typhus (epidemiology and ecology). In: Kazar J, Toman R, eds. Rickettsiae and rickettsial diseases. Bratislava, Slovak Republic:VEDA, 1996.
   

2. 2

   Furuya Y, Yoshida Y, Katayama T, Yamamoto S, Kawamura A Jr. Serotype-specific amplification of Rickettsia tsutsugamushi DNA by nested polymerase chain reaction. J Clin Microbiol 1993;31:1637-1640
   Web of Science | Medline

3. 3

   Deller JJ Jr, Russell PK. An analysis of fevers of unknown origin in American soldiers in Vietnam. Ann Intern Med 1967;66:1129-1143
   Web of Science | Medline

4. 4

   Watt G, Chouriyagune C, Ruangweerayud R, et al. Scrub typhus infections poorly responsive to antibiotics in northern Thailand. Lancet 1996;348:86-89
   CrossRef | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   Veasna Duong, Trinh Thi Xuan Mai, Kim Blasdell, Le Viet Lo, Claire Morvan, Sreyrath Lay, Wichittra Anukool, Patimaporn Wongprompitak, Yupin Suputtamongkol, Denis Laurent, Beat Richner, Chheang Ra, Bui Trong Chien, Roger Frutos, Philippe Buchy. (2011) Molecular epidemiology of Orientia tsutsugamushi in Cambodia and Central Vietnam reveals a broad region-wide genetic diversity. Infection, Genetics and Evolution
   CrossRef

2. 2

   Seong Heon Wie, U Im Chang, Hyung Wook Kim, Jian Hur, Sang IL Kim, Yang Ree Kim, Moon Won Kang. (2008) Clinical Features of 212 Cases of Scrub Typhus in Southern Region of Gyeonggi-Do and The Significance of Initial Simple Chest X-Ray. Infection and Chemotherapy 40:1, 40
   CrossRef

3. 3

   Jean B. Nachega, Emmanuel Bottieau, Francis Zech, Alfons Van Gompel. (2007) Travel-Acquired Scrub Typhus: Emphasis on the Differential Diagnosis, Treatment, and Prevention Strategies. Journal of Travel Medicine 14:5, 352-355
   CrossRef

4. 4

   George Watt, Pacharee Kantipong. 2007. Orientia tsutsugamushi and Scrub Typhus. , 237-256.
   CrossRef

5. 5

   S. D. Blacksell, N. J. Bryant, D. H. Paris, J. A. Doust, Y. Sakoda, N. P. J. Day. (2007) Scrub Typhus Serologic Testing with the Indirect Immunofluorescence Method as a Diagnostic Gold Standard: A Lack of Consensus Leads to a Lot of Confusion. Clinical Infectious Diseases 44:3, 391-401
   CrossRef

6. 6

   Mogens Jensenius, Richard Montelius, Dag Berild, Sirkka Vene. (2006) Scrub typhus imported to Scandinavia. Scandinavian Journal of Infectious Diseases 38:3, 200-202
   CrossRef

7. 7

   C. D. Ericsson, M. Jensenius, P.-E. Fournier, D. Raoult. (2004) Rickettsioses and the International Traveler. Clinical Infectious Diseases 39:10, 1493-1499
   CrossRef

8. 8

   VIRAT SIRISANTHANA, THANYAWEE PUTHANAKIT, THIRA SIRISANTHANA. (2003) Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. The Pediatric Infectious Disease Journal 22:4, 341-345
   CrossRef

9. 9

   Alan J. Magill. (1998) FEVER IN THE RETURNED TRAVELER. Infectious Disease Clinics of North America 12:2, 445-469
   CrossRef