SAEM Clinical Images Series: Fever with Rash
A 40-year-old male, tailor by occupation, was brought to the Emergency Department with complaints of high-grade fever for the past 11 days. Fever was documented to be 102°F and was not associated with any chills or rigors. The patient also complained of shortness of breath for one week associated with a dry cough, as well as an altered sensorium for one day. The patient during his hospital stay developed ARDS and was on mechanical ventilation for 20 days. He was then extubated and discharged after 27 days.
Skin: Multiple eschars on knee, foot, and lower chest.
Complete Blood Count: WBC 31,000; Plt 12,000
BUN: 215 mmol/L
Creatinine: 2.5 mmol/L
Liver Function Tests: AST 192 IU/L; ALP 591 IU/L
Blood PCR for Scrub Typhus was found to be positive.
Scrub typhus is often diagnosed clinically based on exposure to endemic regions and its characteristic eschar, which usually appears on the lower extremities, axillae, or genital region. [1,2] Still, diagnosis can be tricky, and similar eschars can be caused by spider bites, Mediterranean spotted fever, Queensland tick typhus, African tick-bite fever, and anthrax. [3] Scrub typhus is a potentially fatal mite-borne rickettsial infection caused by Orientia tsutsugamushi. It is endemic to the Asia–Pacific region, which has an estimated 1 million instances per year. Those affected may have headaches, myalgias, hearing loss, and rash, in addition to fever. Encephalitis, hepatitis, and pulmonary and cardiac involvement can occur. [1,2]
Early empiric treatment with Doxycycline is life-saving.
Take-Home Points
- Consider Scrub Typhus in a patient presenting with eschars.
- Early empiric treatment with Doxycycline is life-saving.
- Botelho-Nevers E, Raoult D. Fever of unknown origin due to rickettsioses. Infect Dis Clin North Am. 2007 Dec;21(4):997-1011, ix. doi: 10.1016/j.idc.2007.08.002. PMID: 18061086.
- Hendershot EF, Sexton DJ. Scrub typhus and rickettsial diseases in international travelers: a review. Curr Infect Dis Rep. 2009 Jan;11(1):66-72. doi: 10.1007/s11908-009-0010-x. PMID: 19094827.
- Shiao CC, Lin SY. Eschar: a clue to scrub typhus. CMAJ. 2011 Oct 18;183(15):E1152. doi: 10.1503/cmaj.101929. Epub 2011 Sep 12. PMID: 21911554; PMCID: PMC3193135.