నైరూప్య

Rickettsial meningoencephalitis-rising concern in children.

Prakash VJ*, Kalyanshettar SS, Patil MM, Patil SV

Introduction: Rickettsial fever has been reported to be endemic in many parts of India among the adult population. Rickettsial fevers are re-emerging infections with various clinical manifestations and difficult to diagnose. Neurological manifestations are seen many children with rickettsial fever. Studies found that the most common neurological features of rickettsial fever include meningitis, encephalitis, and acute disseminated encephalomyelitis. Pediatric data on rickettsial meningoencephalitis is limited in India and other developing countries. This study explains the clinical and lab profile of children with rickettsial meningo encephalitis.

Methods: We did observational study in the period between January 2019 to December 2020 at Pediatric ICU of BLDE (deemed to be University) Shri BM Patil Medical College and hospital, a tertiary-care centre in Vijayapura, Karnataka, India. Children who were diagnosed as Rickettsial fever on clinical parameters and got confirmed by Weil-Felix test were included in the study. A titre of >1:160 of any of the three antigens (OX2, OX K, OX19) were considered as positive Weil Felix test. Rickettsial meningoencephalitis was diagnosed among these rickettsial fever patients in the presence of 2 of the following 3 features. 1) Altered sensorium/consciousness 2) Alteration in behaviour or cognition and 3) Seizures, along with CSF analysis suggestive of infection. Demographic data, clinical features, laboratory parameters, hospital course, and complications were studied in this group of patients. They were treated as per the standard treatment protocols.

Results: A total of 52 children were found to have Rickettsial fever in the study period from January 2019 to December 2020 (two years). Among these 16 children showed CNS involvement and diagnosed to have rickettsial meningoencephalitis. They were in the age group of 1 to 12 years (median age 3 years), 9 (56.2%) were males, 7 females (43.7%). Symptom wise all of them (100%) had fever, 15 (93.7%) had altered sensorium, 13 (81.2%) had convulsions, 10(%) had behavioral changes, 6 (37.5%) with vomiting. Examination findings showed 12 children (75%) had maculopapular rashes, 4 (25%) had eschar, 3 (18.7%) Skin vasculitis, 9 (56.2) had meningeal signs, 12 (75%) had hepatomegaly and 11 (68.7%) had splenomegaly. They developed complications like septic shock in 6 (37.5%), myocarditis in 1 (6.2%), ARDS in 3 (18.7%) and hemiparesis in 3 (18.7%) children.

Lab evaluation showed predominantly leucocytosis, thrombocytopenia and hyponatremia. Weil-Felix test among these children showed have high titres of OX 2(81.2%), OX 19(25%), OX K (6.25%). CSF study among these children showed mean total leucocyte count of 142, neutrophils 57%, lymphocyte 46%, mean glucose of 49.2 and protein of 67.8. Their mean PICU stay was 6 days. Three (33.3%) children required mechanical ventilation. All 16 (100%) children improved without any neurological sequelae with completely intact neurological status.

Conclusion: Children with acute febrile encephalopathy associated with rash, hepatosplenomegaly and thrombocytopenia should get investigated for rickettsial fever. Timely management with doxycycline and azithromycin and supportive measures can bring excellent outcome in children with rickettsial meningoencephalitis.