Torsades de Pointes by Azithromycin in Scrub Typhus and Review on Cardiac Manifestations of Scrub Typhus

Azithromycin shows a comparable therapeutic efficacy to doxycycline against mild to moderate scrub typhus. It is safe enough to use in pregnant women or children less than 8 years of age, but may be associated with fatal cardiac dysrhythmia. Herein we report a case of scrub typhus in which torsades de pointes developed during treatment with intravenous azithromycin. A 63-year-old man with a history of hypertension and prolonged QT interval was admitted because of fever with duration of 13 days, rash, an eschar, and delirium. An initial electrocardiography showed atrial fibrillation with rapid ventricular response. Scrub typhus complicated by meningoencephalitis, pneumonitis, and possible myocarditis was diagnosed. Two 500 mg doses of azithromycin were infused over 30 minutes, 12 hours apart. The patient developed a cardiac arrest due to torsades de pointes 30 minutes after the second dose of azithromycin. After the patient was resuscitated successfully and the antibiotic was change to doxycycline. The patient eventually improved and was discharged without any sequelae.