Scrub Typhus in a Kidney Transplant Patient

Dear Editor,

Scrub typhus is a vector-borne disease transmitted by the bite of a trombiculid mite and is caused by the bacterium Orientia tsutsugamushi.¹ Although it is a common cause of fever in the Indian subcontinent, there is little information about scrub typhus in transplant recipients. To date, only one other case of scrub typhus in a kidney transplant recipient has been reported.²

We treated a 60-year-old male kidney transplant recipient who presented with a 15-day history of fever along with headache, dry cough, myalgia, and a rise in serum creatinine from 2 mg/dL to 4 mg/dL. Common possible causes of acute febrile illness, including, imaging with CT scan, cytomegalovirus serology, malaria, dengue, and enteric fever, were ruled out, and a test for scrub typhus IgM ELISA was positive with a value of 2.13 (normal < 0.9). He was started on tablet doxycycline 100 mg twice daily. His fever subsided within 24 h, and graft kidney function improved.

This case report highlights the importance of considering scrub typhus in the differential diagnosis of fever of unknown origin in kidney transplant recipients, especially in the Indian subcontinent. Typical painless eschar may be seen at the site of a bite in 40%–50% of patients; hence, the absence of eschar does not rule out this infection.³ Diagnosis can be confirmed by scrub typhus IgM ELISA, but this may be absent in the early phase of the disease. Polymerase chain reaction can be done, with the sensitivity ranging from 80% to 90%.⁴

Clinicians should be aware of the clinical presentation of scrub typhus and should have a high index of suspicion in kidney transplant recipients with fever of unknown origin. Early diagnosis and treatment with doxycycline is essential to prevent severe complications. Azithromycin is an alternative agent that can be used.