Pancreatitis in Scrub Typhus
A 48-year-old female homemaker from a rural area was admitted with complaints of intermittent high fever, abdominal pain and vomiting, and reduced urine output. On examination, she had a pulse rate of 110/min, blood pressure 130/80 mmHg and was afebrile. Conjunctiva were pale and sclera were icteric and no rash was noted. On abdominal examination, diffuse tenderness was elicited and hepatomegaly was present. Hemoglobin was 8.0 g/dL, platelet count 64,000/μL, leukocyte count 10,300/μL with 78% neutrophils and 18% lymphocytes. Erythrocyte sedimentation rate was 88/min. Total bilirubin was 3.5 mg/dL, direct bilirubin 2.3 mg/dL, aspartate aminotransferase 47 IU/L, alanine aminotransferase 64 IU/L and alkaline phosphatase 125 IU/L. Total protein was 6.4 g/dL, albumin and globulin were 3.1 g/dL and 3.3 g/dL, respectively. Serum urea was 174 mg/dL and creatinine was 4.5 mg/dL. Urine analysis revealed 2-4 white cells/high power field, 15-20 red cells/high power field and no casts. Serum amylase was 2662 U/L and lipase was 3822 U/L. The test for malarial parasite by quantitative buffy coat was negative. Blood culture remained sterile after 7 days of incubation and immunoglobulin M (IgM) antibodies to leptospira by enzyme linked immunosorbent assay (ELISA) were negative. Weil-Felix test showed significant titers of OX K - 1:320, OX 19 - 1:80, OX 2 - 1:40 and IgM antibodies to Orientia tsutsugamushi by ELISA were positive.\nThe patient was treated with doxycycline 200 mg/day and ceftriaxone 2 g/day alongside supportive measures. The initial ultrasound scan performed on the 3rd day of admission revealed hepatosplenomegaly, features of acute medical renal disease and ascites. No abnormalities were noted in the pancreas. However, the patient continued to have abdominal pain and a review ultrasound scan was performed on the 9th day, which showed fluid along the body of the pancreas in the lesser sac indicative of a pancreatic pseudocyst. Contrast enhanced computerized tomography of the abdomen was not carried out in view of the deranged renal parameters. The patient was stable upon discharge on the 11th day and on follow-up 6 weeks later, all symptoms had resolved. Lab investigations through the course of hospital stay are given in .