Figure 3: Decreased facial crease on left side.
The complete blood count revealed a total leucocyte count (TLC) of 6000/mm with 40% neutrophils, 50% lymphocytes, 8% monocytes, and 2% eosinophils. The hemoglobin was 9.4 g/L with a mean corpuscular volume of 79 fL and the platelet count was 320000/mcL. There was mild hepatic dysfunction with aspartate transaminase of 63 IU/L and alanine transaminase of 66 IU/L. Total serum bilirubin was 0.5 mg/dL and albumin was 4 g/dL. Serum sodium, potassium, calcium, and phosphorus were within normal limit. The renal functions were normal with urea of 16 mg/dL and creatinine of 0.8 mg/dL.
Blood and urine cultures were sterile. Serological tests for dengue IgM antibodies and NS1 antigen, herpes simplex and Japanese B encephalitis IgM antibodies were negative. Simultaneous search for other tropical infections like malaria, and leptospirosis were negative, however, Scrub IgM was positive. A guarded lumbar puncture was performed and the CSF analysis yielded a cell count of 16 cells μ/L with 80% lymphocytes and 20% neutrophils. Total protein was elevated to 125 g/dL, glucose was 82 mg/dL and adenosine deaminase was 2.5 IU/L. No organism was seen on the Gram stain, Ziehl-Neelsen stain, and India ink stain. CSF cultures were sterile and PCR was negative for herpes simplex virus (HSV) and Mycobacterium tuberculosis. The Magnetic resonance imaging (MRI) of brain was done and MRI of brain reveled multiple mildly increased T2DM/FLAIR signal in midbrain, pons and in left middle cerebellar peduncle (Figures 4, 5 and 6).
Ceftriaxone, which was already started at the center where she was referred, was continued and the dose was doubled to 2gm two times per day. Acyclovir was added intravenously at a dose of 500 mg times per day and was discontinued after exclusion of herpes simplex encephalitis. Dexamethasone was started at a high dose (1gm) to ease cerebral edema. Ceftriaxone was substituted with doxycycline 100 mg two times per day intravenously after scrub typhus was diagnosed. Two days later, the fever subsided, and gradually she was able to communicate verbally and eat on her own. Objective improvement was documented on MRI. Doxycycline was administered for a total of 2 weeks.