Isolated Abducens Nerve Palsy as a Rare Presentation of Scrub Typhus in a Pediatric Patient: A Case Report

Evidence suggest that central nervous system (CNS) involvement in scrub typhus can be observed in approximately 20% of patients, although cranial nerve palsy especially isolated abducens nerve palsy (ANP) is rare. The present report explored the case of a young girl with scrub typhus who presented with fever and ANP.

An 11-year-old girl reported a one-week history of fever and a three-day episode of left eye deviation. Examination revealed restricted abduction of the left eye, indicating lateral rectus palsy, without signs of increased intracranial pressure. Initially, meningitis was suspected, and she was initiated with ceftriaxone. Laboratory tests showed anemia (hemoglobin 80 g/L), elevated inflammatory markers (ESR 136 at 1 hour, C-reactive protein 31 mg/L), and transaminitis (AST 157 IU/L, ALT 75 IU/L). Blood cultures, cerebrospinal fluid analysis, and neuroimaging results were insignificant. Further investigation for infectious causes indicated positive serology for scrub typhus via IgM enzyme-linked immunosorbent assay (ELISA). She was then treated with intravenous doxycycline (5 mg/kg/d), resulting in defervescence within 24 hours, and her ANP resolved after seven days. She remains in good health during follow-up.

Diagnosing scrub typhus was established on characteristic clinical features such as eschar and laboratory tests, including immunofluorescence assays and ELISA with paired sera. In current case, the rapid response to doxycycline and positive IgM-ELISA in the acute phase confirmed the diagnosis.

To conclude, scrub typhus presenting with ANP exhibit a complicated diagnosis which causes further delay in treatment, resulting in increased morbidity and mortality. Pediatricians should be aware of this treatable cause of nerve palsy, as timely intervention can accelerate recovery process.

Source: Gogoi G, Kalita A, Das R. et al. Abductor Palsy in Scrub Typhus. Indian J Pediatr. 2024. https://doi.org/10.1007/s12098-024-05376-8