Acute demyelination of the medulla oblongata owing to scrub typhus in a 7-year-old boy: case report

Scrub typhus caused by Orientia tsutsugamushi is a re-emerging infection in India. In children, it presents with a variety of symptoms, including the comparatively rare and less studied neurological manifestations. A 7-year-old boy presented with sudden onset difficulty in walking, respiratory distress, slurring of speech and a history of fever. There were acute cerebellar signs followed by quadriparesis with hypertonia, exaggerated deep tendon reflexes, bilateral extensor plantar response and loss of spontaneous respiratory effort, requiring mechanical ventilation on Day 3. Complete blood count (CBC) demonstrated lymphocytic leucocytosis; cerebrospinal fluid (CSF) analysis was normal. Owing to a suspected demyelinating disorder, he was commenced on intravenous (IV) pulse methylprednisolone 30 mg/kg . CSF and blood were positive for scrub typhus infection and on Day 5 he was commenced on IV azithromycin 10 mg/kg. On Day 7 there was considerable neurological improvement with reduction of raised intracranial pressure and on Day 9 he was extubated. Magnetic resonance imaging (MRI) of brain on Day 10 suggested low-grade glioma or demyelination in the medulla oblongata. Subsequent magnetic resonance spectroscopy findings supported a demyelinating disorder. After completing the course of methylprednisolone, he was commenced on oral corticosteroids and, during discharge, there was only minimal residual neurological abnormality. After discharge, prednisolone was gradually tapered over 6 weeks and the 3-month repeat MRI demonstrated considerable improvement with only a small focus of demyelination visible around the medulla. This is the first paediatric case of scrub typhus-induced cerebellitis and acute demyelination of the medulla that responded well to corticosteroid therapy.