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Weekly Chest CasesArchive of Old Cases

Case No : 854 Date 2014-03-07

  • Courtesy of Bo Young Jeong, Jeung Sook Kim / Dongguk University Ilsan Hospital, Gyeonggi-do, Korea
  • Age/Sex 56 / F
  • Chief ComplaintFever, skin rash of face, neck and both arms(Duration: 2 days)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Scrub Typhus (Tsutsugamushi disease)
Radiologic Findings
Initial chest PA shows increased interstitial opacities in both lungs. Blunting of bilateral costophrenic angles is noted.
Lung setting of the chest CT images show interlobular septal thickening and multifocal patch ground-glass opacities which are patterns of the interstitial pneumonia in both lungs. Mediastinal setting of chest CT image shows enlargement of both axillary and para-aortic lymph nodes. There are also small amount of bilateral pleural effusion.
Laboratory data of the patient showed positive for O. tsutsugamushi antibody, mild LFT abnormality and increased CRP (C-reactive protein).
Brief Review
Scrub typhus (tsutsugamushi disease) is an acute febrile illness caused by Orientia tsutsugamushi, characterized by focal or disseminated vasculitis and perivasculitis, which may involve the lungs, heart, liver, spleen, and central nervous system. Scrub typhus has epidemics in the late fall that affect a wide area of South-East Asia and the Pacific rim including the Korean Peninsula. It is transmitted to humans by the bite of mites or chiggers.
The diagnosis of scrub typhus is based on history of exposure, clinical features and serological testing. The main clinical manifestations are high fever, skin rash, myalgia, lymph node enlargement and characteristic eschar formation at the site of chigger feeding. The clinical course is usually mild and self-limited with spontaneous recovery after a few days, but some patients have a more severe course which may be fatal.
The radiological findings of scrub typhus are variable, ranging from normal to fulminant pulmonary edema. On chest radiography, bilateral diffuse areas of reticulonodular opacity, hilar lymph node enlargement, and septal lines are the most common findings. Airspace consolidation is relatively uncommon and generally appears in the lower zone of both lungs. Unilateral or bilateral pleural effusion is common, found in 12-43% of patients. On high-resolution CT, interlobular septal thickening, axial interstitial thickening, ground-glass opacity, and centriloular nodules with lower lung predilection are common findings. Consolidation and large nodules are less common. CT findings of scrub typhus may reflect cellular infiltration, edema, and hemorrhage caused by vasculitis or may be due to interstitial edema secondary to cardiac involvement.
The differential diagnosis of scrub typhus is pulmonary interstitial edema and pulmonary interstitial pneumonia such as viral pneumonia, Mycoplasma pneumonia, and Pneumocystis Jiroveci pneumonia etc.
References
1. Choi YH, Kim SJ, Lee JY, Pai HJ, Lee KY, Lee YS. Scrub typhus: radiological and clinical findings. Clin Radiol 2000; 55:140-144.
2. Jeong YJ, Kim S, Wook YD, Lee JW, Kim KI, Lee SH. Scrub typhus: clinical, pathologic, and imaging findings. Radiographics 2007; 27:161-172.
Keywords
Lung, Multiple organ, Infection,

No. of Applicants : 86

▶ Correct Answer : 23/86,  26.7%
  • - Inha university hospital , Korea (South) Eugene Kim
  • - Niigata City General Hospital , Japan Takao Kiguchi
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Kyoto University , Japan Akihiko Sakata
  • - Chonnam National University Hospital , Korea (South) Sungmin Moon
  • - GHICL , France manuel toledano
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - , Korea (South) Chan Park
  • - , Korea (South) Kim sungmo
  • - Ansan Sarang Hosp. , Korea (South) Jaecheon Oh
  • - Gachon Gil hospital , Korea (South) junhyung Ann
  • - Samsung medical center , Korea (South) Hyun Su Kim
  • - Onomichi Municipal Hospital , Japan Yoshihisa Masaoka
  • - Oita University , Japan Haruka Sato
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - kanto Rosai Hp , Japan Takana Yamakawa
  • - Kyungpook national universtiy hospital , Korea (South) Hong Jihoon
  • - C.B.H. Dpt of Imaging- Clinica MATER DEI - BARI , Italy Carlo Florio
  • - Teikyo University Mizonokuchi Hospital , Japan Kaoru Sumida
  • - Chonnam National University Hospital , Korea (South) So yeon Ki
  • - Medicheck health care , Korea (South) Chae Lim
  • - All India Institute of medical sciences , India Justin Moses
▶ Correct Answer as Differential Diagnosis : 18/86,  20.9%
  • - Tokyo Metropolitan Police Hospital , Japan Akifumi Hagiwara
  • - Asan medical center , Korea (South) Sang Young Oh
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - , Korea (South) yun young lee
  • - Chonnam national university hospital , Korea (South) INSOO JANG
  • - Chonnam national university hospital , Korea (South) Gunsoo Kim
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - IRSA La Rochelle , France Denis Chabassiere
  • - 異⑸ , Korea (South) sooncheul baek
  • - Hanyang universitiy, radiology department , Korea (South) HyunGyu Lee
  • - CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
  • - 異⑸ , Korea (South) Jung Kim
  • - ICD,MCH CALICUT , India rikhy krishnan
  • - Private sector , Greece Vasilios Tzilas
  • - NASA SCANS , India RAKESH BHATIA
  • - CNUH , Korea (South) Noh Hoon
  • - CNUH , Korea (South) Kim Soo Hyun
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Current Editor : Sung Shine Shim, MD, PhD. Email : sinisim@ewha.ac.kr

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