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Weekly Chest CasesArchive of Old Cases

Case No : 732 Date 2011-11-07

  • Courtesy of Youkyung Lee, Tae Jung Kim, Kyung Won Lee / Seoul National University Bundang Hospital
  • Age/Sex 20 / M
  • Chief ComplaintFever, dyspnea, and eschar on right arm.
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 7
  • Figure 8

Figure 1. 1 week ago.

Diagnosis With Brief Discussion

Diagnosis
Scrub typhus (Tsutsugamushi disease)
Radiologic Findings
High resolution CT scan shows interlobular septal thickening, bronchovascular bundle thickening, and multifocal ground-glass opacities which are patterns of the interstitial pneumonia and bilateral pleural effusion. Both axillary lymph nodes are enlarged. Initial chest radiograph shows increased interstitial opacities and reticular opacities in both lungs. Followed chest radiograph shows increased the extent of hazy consolidation in both lungs and a rapid improvement.
Brief Review
Scrub typhus (tsutsugamushi disease) is an acute febrile illness caused by Orientia tsutsugamushi. It is transmitted to humans by the bite of mites or chiggers. 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. Scrub typhus involves multiple organs including the lung, heart and central nervous system and is characterized by focal vasculitis or perivasculitis seceondary to direct endothelial injury. The diagnosis of scrub typhus is based on history of exposure, clinical features and serological testing. The main clinical manifestations are high fever, chill, headache, skin rash, myalgia, lymph node enlargement and characteristic eschar formation. The latent period of the disease is 6 to 18 days. 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, parenchymal abnormalities with lower lung predilection including bilateral reticulonodular opacities, groun-glass opacities, consolidation, septal lines and hilar lymph node enlargement, cardiomegaly and pleural effusions. On thin-section CT, ground-glass opacity with a gravitational distribution, bronchial wall thickening, intralobular septal thickening and centrilobular nodules which may reflect the interstitial pneumonia. 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, infection, parasitic,

No. of Applicants : 94

▶ Correct Answer : 59/94,  62.8%
  • - Mackay Memorial Hospital, Taipei , Taiwan Sheng-Yeh Shen
  • - Severance hospital , Korea (South) Beomseok Sohn
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Fukuyama daiichi Hospital , Japan Mototsugu Saeki
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Okayama University , Japan Akihiro Tada
  • - Dong-A University Hospital , Korea (South) Ji-yeon Han
  • - Catholic medical center , Korea (South) hyuna kim
  • - Inha University Hospital , Korea (South) Ju Won Lee
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - Az Osp Santa Maria Terni , Italy angelo carloni
  • - radiologist, aditya imaging centre , India vivek patel
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Suncheon Plus Medicine , Korea (South) Park Sang Hyun
  • - Korea university , Korea (South) SUMIN HA
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - Seoul National University Hospital , Korea (South) Hyungjin Kim
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Seoul national university hospital , Korea (South) A Jung Chu
  • - Dong-A University Hospital , Korea (South) Bo Sung Kim
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - UWO , Canada S Lee
  • - Chungnam National University hospital , Korea (South) sunkyoung you
  • - Samsung medical Center , Korea (South) Ah Kim
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - CHRU lille , France manuel toledano
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Kyungpook National University Medical center , Korea (South) Sunkyung Lim
  • - Onomichi municipal hospital , Japan Ryotaro Kishi
  • - Hanyang Medical Center , Korea (South) Ki Yoon
  • - o2 clinic, pudukottai, india , India siva raja
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - IRSA , France jean-luc BIGOT
  • - Jaseng Oriental Hospital , Korea (South) Byung-June Jo
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - , Korea (South) Sungkwan Kim
  • - Emory University Department of Radiology , United States Travis Henry
  • - SMC , Korea (South) JIHYE MIN
  • - NMC, sunder lal jain hospital , India sanjeev vachher
  • - Chuncheon Sacred Heart Hospital , Korea (South) Park Su-young
  • - National Taiwan University Hospital , Taiwan Li-Ta Keng
  • - Song-do Hospital , Korea (South) Ji-young Yun
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - Gwangju 21st century hospital , Korea (South) Hyungwoo Oh
  • - Seoul St Mary Hospital , Korea (South) Chae Lim
  • - Private sector , Greece Vasilios Tzilas
  • - Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
  • - Vikram hospital , India Pravin Mahadevappa
  • - CNUH , Korea (South) Hyedoo Jung
  • - All India Institute of medical sciences , India Justin Moses
  • - A.P.Chest hospital ,hyderabad , India bhaskar kakarla
▶ Correct Answer as Differential Diagnosis : 4/94,  4.3%
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - All India Institute of Medical Sciences , India Ashish Gupta
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