Abstract

The present clinical case report reveals an outbreak of severe scabies infestation along with tuberculosis among young children of Sahariya tribe of Central India. More predominately young children of the tribe were found severely infested with scabies. Some of them were also registered TB patients. Appropriate clinical tests were performed to identify the actual cause of outbreak and hematological analysis of blood sample was carried out to diagnose the clinical disease. ESR, lymphocyte counts and serum LDH content was found significantly (p<.05) elevated in affected children and adult subjects, indicating the pathogenic infection (tuberculosis) and infestation (scabies) induced pathology.Weak immunity resulting from malnutrition, poor hygiene and lack of proper Medicare, in these rural and remote areas are the main predisposing factors till today. There is a need of regular follow up of local hygiene and medical facilities available in these areas followed by appropriate and timely treatment to them.

Introduction

Sahariya is a primitive tribal group of central India. It is a landless community, which migrate to neighboring states in search of labor and wages during crop harvesting season. During such migration, people carry with themselves several opportunistic infections as one encountered in the present case study. The tribe lives in different villages isolated from main urban population. Population-wide surveys of Sahariya tribe for TB, carried out earlier, have reported significantly high incidence of tuberculosis in the tribe 12 . During a mass camping, organized for blood sampling of tuberculosis patients of Sahariya, heavy infection of scabies was recorded.

Although, scabies infection was spread to most of the tribal villages, the present observation was made from a representative village, Goras (District Sheopur). Most of the young children of 7-15 years of age from this village were found severely infested by the mite, Sarcoptes scabiei. The hospital record on registered TB cases from this village indicates a ratio of 16 TB patients per 1000 individuals (the total population of village is about 2500). Skin infections causing rash and lesions are frequently used as indicators of patient’s immunological status. It is found to be the most frequent (in almost 95% of cases) problem in people living with HIV/AIDS 3 . Insufficient medical facilities, malnutrition and lack of vaccination against such opportunistic infections are the most likely causes of ill-health and high rates of child morbidity and mortality in tribes and other underprivileged communities of India.

Annual Risk of Tuberculosis Infection in Children: The annual rate of tuberculosis in children below 10 year in India has been found to be more than 1%, which is disappointingly very high 4 . In a study conducted to estimate the annual risk of tuberculosis infection (ARTI) based on PPD (purified protein derivatives) test results showed that ARTI is higher among slum children (2.1%) as compared to non-slum children (1.7%) indicating the correlation between poor socio-economic conditions and annual risk of child tuberculosis 5 . It has been observed that prevalence of TB infection goes up about 14% by the age of 14 67 . In a recent study, carried out in Bhubaneswar, India have shown that among 100 children who were screened for tuberculosis infection, 27% and 72% were found positive for Mantoux (PPD) and ‘BCG test’ , respectively 8 . As most of the above studies have been conducted in general populations which have comparatively better socio-economic conditions than the rural tribal groups like that of Sahariya, the infection rate may be even higher in such underprivileged groups, which are rarely investigated for such infection due to lack of medical facilities, inaccessibility of these tribes, prevailing poor socio-economic condition, etc. Also, it has been observed that the risk of tuberculosis infection significantly increases in children having sputum positive contacts around them than in the general population 9 . Thus, such children become more likely to develop clinically active disease at higher rate as also seen in present study.

Materials & Methods

a. Sampling: The research team organized the blood sampling camp at the Goras village panchayat office about 25 Km. away from the district hospital, Sheopur (M.P.) under the tuberculosis screening programme. Nineteen individuals especially young children were found to have severe skin rash. The patients already undergoing chemotherapy for TB as well as those carrying scabies infection (n=19), alone or in combination with TB, were diagnosed on the spot by the accompanying clinician from district hospital. Out of the four children having TB, two were positive for chest X-ray, while the two were only positive for acid-fast bacilli (AFB) sputum test. These are the only tests easily available as well as technically and economically affordable in the hospital in these areas for primary diagnosis of TB. The scabies infestation was re-confirmed by a specialist dermatologist. After well informed and written consent of the donors (consents were taken from parents in case of minors), blood samples (4-5ml) and skin swabs were collected in sterile vials. The blood sampling and research protocols to work on human samples were approved by Institutional Ethics Committee of Jiwaji University.

b. Hematological test: Hb, TLC and WBC counts was determined by standard Hematological method while, ESR and LDH levels were determined by the methods of Westergren (1921) 12 and Bach et al (1991) 13 , respectively.

c. Microbial culture:

The open wound swabs were cultured on the Czepak dox agar culture medium at 37 ^o C for 48 hrs. to identify any fungal growth (primary or secondary infection) in samples collected from open wounds. The Fungal identification was made on the basis of macroconidia and culture morphology.

Results

The skin infection was clinically diagnosed by the dermatologist as scabies, which is caused by a tiny mite Sarcoptes scabiei. The skin lesions and rash occur due to deep burrowing of mite into the skin, predominantly around digital webs, buttocks, etc. (see Fig. 1A) of the infected individuals.

Figure 1. A. Scabies infested hands and other parts of the tribal children B. Showing the fungal culture observations

The itch and rash are the result of allergic reaction, induced by the mite. Our subjects under investigation, particularly children, showed all of the above symptoms. The hematological parameters revealed, in general, low hemoglobin level (8-12 gm %) in almost all the subjects, specifically those infected with scabies and tuberculosis both, indicating severe anemic conditions. Although, infections were also observed in adults, the intensity of the symptoms was lower. The ESR (Erythrocyte Sedimentation Rate) and serum LDH level were significantly (p<0.05) elevated in scabies infested children (see Table).

Table: Hematology and serum LDH content in the Children of Sahariya tribe infected with Scabies. NK=Not known

The secondary infections observed in swab cultures of open wounds revealed mainly the presence of a human skin infecting fungus, Microsporum canis, with charactristic filamentous mycelium and forms a yellow pigment, which on the reverse side, turned orangish-yellow with age (Fig. 1B). The four of the nineteen children observed were sputum positive for Mycobacyerium tuberculosis (AFB test) carried out at the district TB hospital, Sheopur, during the start of their TB chemotherapy (as per RNTCP, WHO protocols).

Discussion

Earlier studies have reported significantly high incidence of Mycobacterium tuberculosis infection in Sahariya tribe. Scabies has been generally found associated with several pathological infections, including Mycobacterium tuberculosis. Typical manifestations of scabies like crusted or Norwegian scabies has also been seen in HIV patients with low CD4 counts 14 . The present case report indicates that severe scabies outbreak in this tribe may likely be associated directly or indirectly with their increased susceptibility to tuberculosis and or other systemic infections, which are yet to be clinically identified. The most likely reason for this could be the poor and unhygienic life style and lack of proper medical care in such patients, making them immuno-susceptible to a wide variety of pathogenic infections.

Hemoglobin (Hb) concentration in blood stream is considered as a useful indicator of health and nutritional status of any individual or population group. The relatively poor hemoglobin level in the individuals examined in this study presents a direct correlation between their socio-economic conditions and clinical health. It is reported that severely malnourished individuals are likely to have their immune functions impaired 15 and show positive association with the susceptibility to infectitious diseases 16 . The increased ESR, observed in most of our tribal patients, thus, indicates existence of an infective or inflammatory destructive disease like, TB. The serum lactate dehydrogenase level usually goes high in several kinds of skin infections. The elevated serum LDH level in theses subjects further support the presence of physiological stress caused by scabies infestation or other co-infections, including Mycobacterium tuberculosis 2 .

The secondary infection seen in swab cultures of open wounds revealed a human skin infecting fungus, Microsporum canis, with characteristic filamentous mycelia and forms a yellow pigment, which on the reverse side turns orangish yellow with age. Such infections are often observed as a consequence of increased inflammation resulting from tissue rupture following physical activities, like scratching etc. Rapid spread of the infection results from the innocent contact among children, while it remain contained in adults due to the preventive measure they take, as observed in this study also.

Conclusion

Weak immunity to such opportunistic pathogenic infections, resulting from malnutrition, poor hygiene and lack of proper Medicare, in these rural and remote areas are the main predisposing factors till today. Such health problems can be addressed by regular follow up of local hygiene and medical facilities available in these areas followed by appropriate and timely treatment.

Thus, present study stresses for a detailed clinical and detailed biochemical investigations of such outbreaks and their possible associations with other infections, particularly, in children whose immune responses are poor and thus, are more susceptible to pathogenic attacks. Such an outbreak was never reported earlier in this tribe. The knowledge and proper diagnosis of such outbreaks and their possible association with TB or other infections is most essential for tribal health as well as the health of healthcare personnel working with them.

References