Infect Chemother.  2009 Apr;41(2):99-104. 10.3947/ic.2009.41.2.99.

Cholestatic Hepatitis Caused by Tongyeong Strain of Orientia tsutsugamushi

• Joo K
• Kim MK
• Kil SH
• Chung MH
• Kim JM
• Kang JS

• KMID: 2170258
• DOI: http://doi.org/10.3947/ic.2009.41.2.99

Abstract

In Korea, the clinical manifestation of scrub typhus in humans appears to be severe in the northern regions of the country and mild in the southern areas. Studies on the geographic distribution of the serotype of Orientia tsutsugamushi revealed that the Boryong serotype is predominant in the southern Korean peninsula, whereas the Gilliam, Karp, and Gilliam-Karp serotypes prevail in the northern or central peninsula. We report a case of severe scrub typhus caused by the Japanese Gilliam type of Orientia tsutsugamushi in a 66-year-old woman from Tongyeong, a city located in the southern part of Korean peninsula. The patient was admitted to the hospital with fever on August 29th, 2001. Scrub typhus complicated by shock, pneumonitis, and encephalitis was diagnosed. Additionally, markedly elevated alkaline phosphatase levels was observed, which necessitated an ultrasonographic examination, which showed an ill-defined hyperechogenic mass on the right hepatic lobe. Liver biopsy showed cholestatic hepatitis and blood culture showed growth of O. tsutsugamushi. Gene sequencing of the amplicons of a polymerase chain reaction using primers for the amplification of the gene encoding the 56-kDa protein of O. tsutsugamushi revealed a nucleotide sequence that matched Yonchon strain of O. tsutsugamushi.

Keyword

Orientia tsutsugamushi; Scrub typhus; Cholestatic hepatitis; Genotype

MeSH Terms

Aged
Alkaline Phosphatase
Asian Continental Ancestry Group
Base Sequence
Biopsy
Encephalitis
Female
Fever
Genotype
Hepatitis
Humans
Korea
Liver
Orientia tsutsugamushi
Pneumonia
Polymerase Chain Reaction
Scrub Typhus
Shock
Sprains and Strains
Alkaline Phosphatase

Figure

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  Figure 1 Liver biopsy shows mild intraacinar cholestasis in the perivenular area (left) and mild widening of the portal area with lymphocytic, plasmacytic, and neutrophilic infiltration (right). (H&E, ×400)

Reference

1. Chang WH, Kang JS, Lee WK, Choi MS, Lee JH. Serological classification by monoclonal antibodies of Rickettsia tsutsugamushi isolated in Korea. J Clin Microbiol. 1990. 28:685–688.

2. Chong YS, Kim JJ, Kwak CG, Lee SY, Yi KS, Suto T. Isolation of Rickettsia tsutsugamushi from patients in Chinhae area in 1987. J Korean Soc Microbiol. 1989. 24:81–87.

3. Kang JS, Lim BU, Kim YL, Park DC, Jo JT, Lee JK. Serotype of Rickettsia tsutsugamushi isolated in Ulsan area. Korean J Infect Dis. 1992. 24:179–182.

4. Roh JY, Kee SH, Song HJ, Kim SN, Choi YJ, Song KJ, Kim WJ, Hong SM. Identification of serotypes of Orientia tsutsugamushi using nested PCR. Korean J Infect Dis. 1997. 29:183–189.

5. Kim ES, Kim MK, Lee HM, Kil SH, Chung MH, Lee JS, Kang JS. Doxycycline resistance in Orientia tsutsugamushi isolated from Korean patients. Infect Chemother. 2008. 40:259–265.

6. Kim MJ, Kim MK, Kang JS. Improved antibiotic susceptibility test of Orientia tsutsugamushi by flow cytometry using monoclonal antibody. J Korean Med Sci. 2007. 22:1–6.

7. Ree HI, Kim TE, Lee IY, Jeon SH, Hwang UW, Chang WH. Determination and geographical distribution of Orientia tsutsugamushi serotypes in Korea by nested polymerase chain reaction. Am J Trop Med Hyg. 2001. 65:528–534.

8. Park JI, Han SH, Cho SC, Jo YH, Hong SM, Lee HH, Yun HR, Yang SY, Yoon JH, Yun YS, Moon JY, Cho KR, Baik SH, Son JH, Kim TW, Lee DH. Outbreak of hepatitis by Orientia tsutsugamushi in the early years of the new millenium. Korean J Hepatol. 2003. 9:198–204.

9. Allen AC, Spitz S. A comparative study of the pathology of scrub typhus (tsutsugamushi disease) and other rickettsial diseases. Am J Pathol. 1945. 21:603–681.

10. Satoh T, Nagai K, Katoh T, Ishii K, Aikawa K, Inoue K, Hosaka H, Itoh K, Abei T. A case of hepatitis with granulomatous lesions by Rickettsia tsutsugamushi. Nippon Shokakibyo Gakkai Zasshi. 1991. 88:2827–2830.

11. Chien RN, Liu NJ, Lin PY, Liaw YF. Granulomatous hepatitis associated with scrub typhus. J Gastroenterol Hepatol. 1995. 10:484–487.

12. Kanno A, Yamada M, Murakami K, Torinuki W. Liver involvement in tsutsugamushi disease. Tohoku J Exp Med. 1996. 179:213–217.

13. Pongponratn E, Maneerat Y, Chaisri U, Wilairatana P, Punpoowong B, Viriyavejakul P, Riganti M. Electron-microscopic examination of Rickettsia tsutsugamushi-infected human liver. Trop Med Int Health. 1998. 3:242–248.

14. Chang WH, Kee SH, Song HJ, Han HS, Kim KH, Hong SS. Infection rate and serotype distribution of Orientia tsutsugamushi among field rodents in Chollanamdo using nested polymerase chain reaction. J Korean Soc Microbiol. 1997. 32:301–306.

15. Ree HI, Lee IY, Jeon SH, Yoshida Y. Geographical distribution of vectors and sero-strains of tsutsugamushi disease at mid-south inland of Korea. Korean J Parasitol. 1997. 35:171–179.

16. Tamura A, Yamamoto N, Koyama S, Makisaka Y, Takahashi M, Urabe K, Takaoka M, Nakazawa K, Urakami H, Fukuhara M. Epidemiological survey of Orientia tsutsugamushi distribution in field rodents in Saitama Prefecture, Japan, and discovery of a new type. Microbiol Immunol. 2001. 45:439–446.

17. Seong SY, Park SG, Kim HR, Han TH, Kang JS, Choi MS, Kim IS, Chang WH. Isolation of a new Orientia tsutsugamushi serotype. Microbiol Immunol. 1997. 41:437–443.

18. Kim JK, Joo HS, Yang JW, Rhee WY, Yong SJ, Shin GC, Kim HY. Comparison of clinical manifestations of tsutsugamushi disease by serotype. Korean J Intern Med. 2002. 63:S152.

19. Park SD, Chung MH, Lee HM, Kim MK, Kang JS. A case of scrub typhus in summer presenting as atypical pneumonia. Infect Chemother. 2008. 40:241–245.

20. Chung MH, Lee SH, Kim MJ, Lee JH, Kim ES, Kim MK, Park MY, Kang JS. Japanese spotted fever, South Korea. Emerg Infect Dis. 2006. 12:1122–1124.