Methods
Blood and urine investigations revealed anemia (Hb: 6.1 g/dL),
leukocytosis (WBC count: 25.4x109 cells/L) with a
differential count of [N65, L32, M2, E1], and elevated C-reactive
protein (64.8 mg/L). Serum bilirubin was elevated (total: 5.28 mg/dL,
indirect: 4.53 mg/dL), while renal function tests and electrolyte
parameters were within normal limits. Peripheral blood smear showed
anisopoikilocytosis and a reticulocyte count of 1.1% (corrected for
anemia). Reports showed a negative direct Coombs test, significantly
elevated lactate dehydrogenase (LDH: 1784 U/L), low haptoglobin levels
(13 mg/dL). Urinalysis revealed a dipstick positive for heme protein,
with no RBCs or pus cells. The urine test for myoglobin was negative.
The clinical findings and investigation results indicated ongoing
intravascular hemolysis with a likely infectious etiology. Empirical
treatment with intravenous cefotaxime was initiated. However, the
patient’s pallor worsened, and urine continued to be dark throughout the
day, accompanied by several episodes of fever. The patient was
transferred to the pediatric intensive care unit (PICU) for unstable
vital signs (tachycardia and hypotension). In the PICU, additional blood
investigations, including a tropical panel, were conducted, and 2 pints
of packed red blood cells were transfused to address a hemoglobin level
of 3.1 g/dL. The child was found to be positive for anti-Scrub typhus
IgM antibody. The G6PD spectrophotometry revealed an enzyme level of
7.46 U/gm Hb, which is within normal limits. Abiding to the seropositive
status and clinical symptoms suggestive of scrub typhus, oral
azithromycin was added to the treatment.