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.