A descriptive study to quantify severity in patients with severe scrub typhus in hilly city of Northern India


  • Nishant Nadda Department of Civil Hospital, Chail, Solan, Himachal Pradesh, India
  • Nidhi Chauhan Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
  • Anjali Mahajan Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
  • Ankit Chaudhary Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
  • Kritika Katoch Department of Ophthalmology, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
  • Shaina Chamotra Department of Obstetrics & Gynaecology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India




APACHE II, Mortality, Scrub typhus, Severity


Background: Himachal Pradesh is an endemic area for scrub typhus. If not treated early, it can lead to life threatening complications. Therefore, more emphasis needs to be laid on the diagnosis and prompt treatment, so that mortality due to severe scrub typhus can be prevented. So, this study was done with an objective to study the clinical profile of patients diagnosed with severe scrub typhus and assess their severity using APACHE II score in IGMC, Shimla.

Methods: Authors conducted a descriptive cross-sectional study in Indira Gandhi Medical College, Shimla over one year (June 2016-May 2017). Out of 538 confirmed scrub typhus cases, 58 severe cases were reported, and their severity was assessed with predefined criteria of sepsis and APACHE II score.

Results: Mean age of males (50.18±18.6 yrs) was found to be more than that of females (45.52±14.5 yrs), the difference being statistically insignificant t(56)= -1.01, (P=0.32). Fever (100%), headache (84.5%), vomiting (79.3%) were the major presenting symptoms and tachycardia (96.5%), hypotension (87.9%), tachypnoea (94.8%) were the main clinical signs. The mean APACHE II score on admission was 16.25±5.0 with a predicted mortality of 23.5%, that was found to be less than actual reported hospital mortality (25.8%).

Conclusions: APACHE II score was found reliable tool for risk stratification. Case fatality in diagnosed cases of severe scrub typhus was found high. Early diagnosis and prompt treatment according to guidelines would help in decreasing the mortality, financial burden on patient, society and health system.


Watt G, Parola P. Scrub typhus and tropical rickettsioses. Current Opinion Inf Dis. 2003;16(5):429-36.

Varghese GM, Trowbridge P, Janardhanan J, Thomas K, Peter JV, Mathews P, et al. Clinical profile and improving mortality trend of scrub typhus in South India. Int J Inf Dis. 2014;23:39-43.

Brown GW, Robinson DM, Huxsoll DL, Ng TS, Lim KJ, Sannasey G. Scrub typhus: a common cause of illness in indigenous populations. Transactions Royal Soc Trop Med Hyg. 1976;70(5-6):444-8.

Rathi N, Rathi A. Rickettsial infections: Indian perspective. Ind Pe. 2010;47(2):157-64.

Mahajan SK, Rolain JM, Kashyap R, Bakshi D, Sharma V, Prasher BS, et al. Scrub typhus in Himalayas. Emerging Infec Dis. 2006;12(10):1590.

Sundhindra BK, Vijayakumar S, Kutty KA, Tholpadi SR, Rajan RS, Mathai E, Raoult D, John TJ. Rickettsial spotted fever in Kerala. National Med J Ind. 2004;17(1):51-2.

Mathai E, Lloyd G, Cherian T, Abraham OC, Cherian AM. Serological evidence for the continued presence of human rickettsioses in southern India. Ann Tropic Med Parasitol. 2001;95(4):395-8.

Kamarasu K, Malathi M, Rajagopal V, Subramani K, Jagadeeshramasamy D, Mathai E. Serological evidence for wide distribution of spotted fevers and typhus fever in Tamil Nadu. Ind J Med Res. 2007;126(2):128.

Mittal V, Gupta N, Bhattacharya D, Kumar K, Ichhpujani RL, Singh S, Chhabra M, Rana UV. Serological evidence of rickettsial infections in Delhi. Ind J Med Res. 2012;135(4):538.

Mahajan SK, Rolain JM, Kashyap R, Bakshi D, Sharma V, Prasher BS, et al. Scrub typhus in Himalayas. Emerg Infec Dis. 2006;12(10):1590.

Chapman AS, Bakken JS, Folk SM, Paddock CD, Bloch KC. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other healthcare and public health professionals. MMWR Recomm Rep. 2006 Mar 31;55(RR-4):1-27.

Hun L, Troyo A. An update on the detection and treatment of Rickettsia felis. Res Rep Trop Med. 2012;3:47.

Rathi NB, Rathi AN, Goodman MH, Aghai ZH. Rickettsial diseases in central India: proposed clinical scoring system for early detection of spotted fever. Indian Pediatr. 2011;48:867-72.

Raoult D. Orientia tsutsugamushi (scrub typhus). Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 8th Ed;, 2015. Available at: https://www.sciencedirect.com/book/9781455748013/mandell-douglas-and-bennetts-principles-and-practice-of-infectious-diseases#book-description. Last accessed on 20 July 2019.

The Times of India. After 23 deaths, HP issues advisory against scrub typhus, 2018. Available at: https://timesofindia.indiatimes.com/city/shimla/after-23-deaths-hp-issues-advisory-against-scrub-typhus-dengue/articleshow/66126449.cms. (Accessed 03 November 2018).

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-29.

Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine 18th Edi. United States of America: McGraw Hill Education; 2:1696.

Varghese GM, Abraham OC, Mathai D, Thomas K, Aaron R, Kavitha ML, Mathai E. Scrub typhus among hospitalised patients with febrile illness in South India: magnitude and clinical predictors. J Infec. 2006;52(1):56-60.

Sharma PK, Ramakrishnan R, Hutin YJ, Barui AK, Manickam P, Kakkar M, et al. Scrub typhus in Darjeeling, India: opportunities for simple, practical prevention measures. Transac Royal Soc Trop Med Hyg. 2009;103(11):1153-8.

Sharma N, Biswal M, Kumar A, Zaman K, Jain S, Bhalla A. Scrub typhus in a tertiary care hospital in north India. Am J Tropical Med Hyg. 2016;95(2):447-51.

Tsay RW, Chang FY. Serious complications in scrub typhus. J Microbiol Immunol Infec. 1998;31(4):240-4.

Griffith, Matthew and Prakash, John Antony Jude and Peter, John Victor and Pichamuthu, Kishore and Varghese, George. Clinical Profile and Outcomes of Severe Scrub Typhus Infection Requiring Intensive Care Management. Conference: Infectious Diseases Society of America 2009 Annual Meeting. Available at: https://www.researchgate.net/publication/267911612,Clinical_Profile_and_Outcomes_of_Severe_Scrub_Typhus_Infection_Requiring_Intensive_Care_Management.

Vikrant S, Dheer SK, Parashar A, Gupta D, Thakur S, Sharma A, et al. Scrub typhus associated acute kidney injury-a study from a tertiary care hospital from western Himalayan State of India. Renal Failure. 2013;35(10):1338-43.






Original Research Articles