Published: 2019-08-27

Cardiovascular abnormalities in severe scrub typhus

Nishant Nadda, Sanjay Mahajan, Madan Kaushik, Rajeev Merwaha


Background: Himachal Pradesh is an endemic area for scrub typhus. If not treated early, it can lead to life threatening complications, affecting various systems of the body. Hence, this study was done with an objective to study the cardiovascular abnormalities in patients of severe scrub typhus.

Methods: Authors conducted a hospital-based study in Departments of Medicine and Cardiology, of a tertiary care hospital in Sub-himalayan region in patients of severe scrub typhus from June 2016 to May 2017.

Results: Thirty-two (55%) patients were aged <60 years with female preponderance (72%).   Electrocardiographic changes included sinus tachycardia in 56 (97%), axis deviation in 5(9%), ST-T changes in 3(5%) and atrial fibrillation in 1(2%). Echocardiographic changes included tricuspid regurgitation in 14(24%), pericardial effusion in 4(7%), myocarditis in 1(2%) and Regional wall motion abnormality in 1(2%). Left ventricular ejection fraction >45% in 47 (81%) and <45% in 11(19%).  Fifty-one patients had hypotension at presentation and 49 (90%) of them improved. Interestingly, 10 of 11 patients with reduced EF (<45%) survived whereas 6 of total 7 patients, who died, had preserved EF (>45 %).

Conclusions: Severe scrub typhus manifested with ST/T changes, myocarditis, pericardial effusion, arrhythmias, shock and patients with reduced EF on Echocardiography had better outcome.


Echocardiographic changes, Electrocardiographic changes, Scrub typhus,

Full Text:



Watt G, Parola P. Scrub typhus and tropical rickettsioses. Curr Opin Infect Dis. 2003;16(5):429-36.

Silpapojakul K. Scrub typhus in the Western Pacific region. Ann Acad Med Singapore. 1997;26(6):794-800.

Settle EB, Pinkerton H, Corbett AJ. A pathologic study of tsutsugamushi disease (scrub typhus) with notes on clinicopathologic correlation. J Lab Clin Med. 1945;30(8):639-61

Levine HD. Pathologic study of thirty-one cases of scrub typhus fever with especial reference to the cardiovascular system. Am Heart J. 1946;31(3):314-28.

Yotsukura M, Aoki N, Fukuzumi N, Ishikawa K. Review of a case of tsutsugamushi disease showing myocarditis and confirmation of Rickettsia on endomyocardial biopsy. Jpn Circ J. 1991;55(2): 149-53.

Chang JH, Ju MS, Chang JE, Park YS, Han WS, Kim IS et al. Pericarditis due to Tsutsugamushi Disease. Scand J Infect Dis. 2000 Jan 1;32(1):101-2.

Karthik G, Sudarsan TI, Peter JV, Sudarsanam T, Vargahese GM, Kundavaram P et al. Spectrum of cardiac manifestations and its relationship to outcome in patients admitted with scrub typhus infection. World J Crit care Med. 2018;7(1):16.

Munford R. Severe Sepsis and Septic Shock. In Harrison’s Principles of Internal Medicine. Kasper DL, Fauci AS, Hauser SL et al (Edi). 19th Edi. United States of America: McGraw Hill Education; 2015;2;1751.

Bonow RO, Mann DL, Zipes DP, Libby P. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th edition. Philadelphia: Elsevier Science, 2011(9):216.

Sharma PK, Ramakrishna R, Hutina Y, Scrub typhus in Darjeeling, India: opportunities for simple,practical prevention measures. Trans R Soc Trop Med Hyg; 2009;(11):1153-8.

Mahajan SK, Raina R, Singh B, Singh DV, Kanga A, Sharma A et al. Pattern of clinical presentation, laboratory findings and mortality risk among patients of scrub typhus in Western Himalayas. J Assc Physic India. 2016;64(3):26-30.

Hu J, Tan Z, Ren D, Zhang X, He Y, Bao C, et al. Clinical characteristics and risk factors of an outbreak with scrub typhus in previously unrecognized areas, Jiangsu Province, China 2013. PLoS ONE 10(5): e0125999.

Jeong YJ, Kim S, Wook YD, Lee JW, Kim K, Lee SH. Scrub Typhus: Clinical, Pathologic, and Imaging Findings. Radiographics. 2007; 27:161-72.

Vivekanandan M, Mani A, Priya Y S, Singh A P, Sameul J, Purty S. Outbreak of scrub typhus in Pondicherry. J Assoc Physician India. 2010;58(1):24-8.

Vikrant S, Thakur S, Sharma A, Gupta D, Kaushal SS, Kanga A, et al. Scrub typhus associated acute kidney injury-a study from a tertiary care hospital from Western Himalayan state of India. Informa Healthcare. 2013 Nov 1;35(10):1338-43.

Sittywangkul R, Pongprot Y, Silvaliarat R, Oberdorfer P, Jittamala P, Sirisanthana V. Acute fulminant myocarditis in scrub typhus, Annals of tropical Pediatrics 2008;28(2):149-54.

Dhiman P, Sharma A, Raina R, Madhabhavi I, Gupta S. Scrub typhus presenting as acute myocardial infarction. Online J Health Allied Scs. 2012;11(3):11.

Kim DG, Kim JW, Kim SM, Choi YS, Kim SH, Park CG et al. Acute myocardial infarction following scrub typhus. Int J Cardiol. 2007:2; 114(1):e18-20.

Chin JY, Kang KW, Moon KM, Choi YJ, Kim J. Predictors of acute myocarditis in complicated scrub typhus: an endemic province in Republic of Korea. Korean J Intern Med. 2018;33(2):323-30.

Watt G, Kantipong P, Jirajarus K. Acute scrub typhus in Northern Thailand: EKG Changes. South East Asia. J Trop Med Public Health. 2002; 33(2):312-3.

Fang CY, Dennis DT, Lee JB. Electrocardiographic changes in scrub typhus patients. South East Asian J Trop Med Public Health.1977;8(4):503-9.

Marin-Garcia J, Gooch WM, Coury DL. Cardiac manifestation of Rocky Mountain spotted fever. Pediatr.1981;67(3):358-61.

Thap LC, Supanaranond W, Treeprasertsuk S, Kitvatanachai S, Chinprasatsak S, Phonrat B. Septic shock secondary to scrub typhus: characteristics and complications. South east Asian J Trop Med Public Health 2002;33(4):780-6..

Kakihana Y, Ito T, Nakahara M, Yamaguchi K, Yasuda T. Sepsis-induced myocardial dysfunction: pathophysiology and management. J Intensive Car. e2016;4(1):22.

Parrillo JE, Parker MM, Natanson C, Suffredini AF, Danner RL, Cunnion RE, et al. Septic shock in humans. Advances in the understanding of pathogenesis, cardiovascular dysfunction, and therapy. Ann Intern Med. 1990;113(3):227-42.

Parker MM, Shelhamer JH, Bacharach SL, Green MV, Natanson C, Frederick TM, et al. Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med. 1984; 100(4):483-90.

Jardin F, Fourme T, Page B, Loubières Y, Vieillard-Baron A, Beauchet A, et al. Persistent preload defect in severe sepsis despite fluid loading: a longitudinal echocardiographic study in patients with septic shock. Chest.1999;116:1354-9.

Song WH, Kim KT, Ku YM, Park SH, Kim YS et al. Clinical Role of Interstitial Pneumonia in patients with scrub typhus: a possible marker of disease severity. J Korean Med Sci. 2004;19(5):668-73.

Vieillard-Baron A.Heart-lung interactions in the ICU: physiology, evaluation and clinical applications. Ann Transl Med. 2018;6(18):346.