The clinical significance of upper gastrointestinal endoscopy in gastrointestinal vasculitis related to scrub typhus

Background and Study Aims: Scrub typhus is an acute febrile illness caused by Rickettsia tsutslcgamushi-induced vasculitis, which is common in Asia an d the Pacific islands and is sometimes encountered in Western countries bec ause of increased travel and economic changes spurred by world globalizatio n. Skin rash and eschar are typical physical findings on the trunk and extr emities, but endoscopic mucosal changes have not been described in the gast rointestinal tract until now. We aimed to describe different endoscopic cha racteristics of the gastrointestinal manifestation of scrub typhus, to asce rtain the necessity for endoscopy, and to determine correlations between th e degrees of endoscopic lesion and clinical severity, including cutaneous m anifestation. Patients and Methods: Between January 1993 and October 1998, out of 256 scr ub typhus patients, we applied esophagogastroduodenoscopy to 58 patients wh o complained of gastrointestinal symptoms but had no past history of these symptoms. We categorized clinical severity into four grades according to th e degree of six clinical indicators of systemic complications, and endoscop ic findings were graded from I to IV (I, normal, nonspecific hyperemia; II, distinct hyperemia, pete- chiae, purpura; III, superficial hemorrhage, ero sion; IV, ulcer, active bleeding). Results: Endoscopic findings of scrub typhus were characterized by petechia e, superficial hemorrhage, erosion, ulcers, and vascular bleeding (grade I, 14 patients; grade II, 11 patients; grade III, 16 patients; grade IV, 17 p atients). In 83.3 % of patients there was multiple occurrence of lesions wi thout any predilection sites. Clinical severity was graded (grade I, 7 pati ents; grade II, 23 patients; grade LII, 22 patients; grade IV, 6 patients). There was a correlation between clinical severity and endoscopic findings (P < 0.01). The grade of lesion was high in patients with cutaneous lesions (r(s) 0.359, P < 0.01). In two cases of gastric vascular bleeding, complet e hemostasis was achieved by endoscopic hemoclipping. Conclusions: The major endoscopic features that can develop in scrub typhus are superficial mucosal hemorrhage, multiple erosions and ulcers without a ny predilection sites, and unusual vascular bleeding. The endoscopic featur es are related to cutaneous lesions and severity of the disease. Endoscopy is useful for diagnosis and management of gastrointestinal vasculitis relat ed to scrub typhus.