Dr Mattias Larsson. Photo courtesy of Family Medical Practice

Dr Mattias Larsson

Ngọc is an energetic 13-year-old girl who likes to be outdoors and play with friends, as she lives in the countryside in a province near Hà Nội and she has nice woods and mountain areas she can venture in. Her parents are academics working in education but also have a small-scale farm for house needs with vegetables, fruits and some pigs and chickens. She likes to help with the farm work when not busy studying or out with friends.

One day after being out camping with some friends she developed a high fever and headache, she also felt nausea with stomach pain and vomited a few times. The parents first gave her some paracetamol and hoped the symptoms would improve. However, the fever continued, and she also developed shortness of breath and rash.

As the parents grew more anxious, they took her to the local clinic where they examined her, said it was a bacterial infection and prescribed an antibiotic, Augmentin, and steroids. After some days of treatment, she had not improved, but the symptoms became even more pronounced. She developed a generalised swelling. The appetite was gone, she did not want to eat. The parents then took her to the provincial pediatric hospital where they could do some diagnostics, they took tests for dengue, influenza A, COVID all negative, the CRP was high and CBC indicated a severe infection. She was admitted and given IV antibiotics and other medication. After some days she felt better and could eat and drink. But when she was discharged the condition rapidly deteriorated, and the symptoms returned.

The parents then took her to Hà Nội, first to one of the big national hospitals, but as they had no referral letter, they could not use the health insurance, also there were a lot of patients and long waiting times of several hours. The parents had heard that Family Medical Practice has good competence and diagnostic capacity. When they arrived, they registered quickly and could just after a few minutes see the pediatrician who asked about the symptoms and earlier diagnostics. They said she had now been sick with fever, headache, nausea, stomach pain, vomiting, rash and increased swelling, they told her about earlier healthcare contact and showed the tests and medical reports including the treatments. As no one else in the surroundings had similar symptoms it was not an obvious person-to-person transmission. 

The doctor examined her and in addition to the mentioned symptoms also found enlarged liver and lymph nodes. When asked if she except for the rash had any other marks or lesions on the skin she said she had one that had developed as she got the symptoms in the groin, she had been reluctant to show that as it was in a private area. When examined the pediatrician found a black circular mark, an eschar (a lesion after a mite bite). In addition to conventional infection tests as CBC and CRP he also ordered a Rickettsia PCR test, the tests showed severe infection and the PCR confirmed the diagnosis Rickettsia.

The pediatrician explained that rickettsial infections are often underdiagnosed because of similar symptoms to many other infections, that Scrub typhus is the most common rickettsial disease, and that they are mostly transmitted in the countryside. Rickettsial diseases are caused by infection with intracellular bacteria transmitted to humans by mites, ticks, fleas and lice. The clinical symptoms vary widely, ranging from mild to life-threatening illness depending upon the rickettsial species or strain, underlying diseases, and delay in time to appropriate medical care. As it is an intracellular bacterium it does not respond to the most common antibiotics as Augmentin but more targeted antibacterial treatment is needed.

The right antibiotic treatment to treat rickettsial infections was prescribed as well. After some days the fever symptoms subsided, Ngọc was well again.

Rickettsial diseases are widely distributed in all regions of Việt Nam. The symptoms are often nonspecific and easy to be misdiagnosed with other febrile infections such as dengue fever and influenza A. If you or your child has symptoms with high fever, headache, rash or abdominal pain it’s important to go to a health facility with competence for differential diagnosis to get the right diagnosis and treatment. Family Medical Practice

*Dr Mattias Larsson is a paediatric doctor at Family Medical Practice and associate professor at Karolinska Institutet and has a long experience in research on infectious diseases, especially antibiotic resistance and hospital-acquired infections as well as HIV, with many articles in peer-reviewed publications and mainstream media appearances.

He has worked with the Oxford University Clinical Research Unit, USAID, the Clinton Foundation, and the Ministry of Health of Việt Nam. He is fluent in English, Swedish, Vietnamese, German and some Spanish.

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