Journal of Dr. NTR University of Health Sciences

: 2018  |  Volume : 7  |  Issue : 4  |  Page : 298--300

Lesson learnt from a missed case of scrub typhus: An interesting case report

Murugaprakash Bagavathinathan1, Prabha Thangaraj2,  
1 Mount Tabor Medical Mission Hospital, Mathur, Pudukkottai, India
2 Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Irungalur, Trichy, Tamil Nadu, India

Correspondence Address:
Dr. Prabha Thangaraj
Department of Community Medicine, Trichy SRM Medical College Hospital and Research Centre, Irungalur, Trichy, Tamil Nadu


The diagnosis of scrub typhus, though endemic in several parts of India, is missed due to various reasons such as nonspecific presentation of symptoms, lack of knowledge among treating physician, and poor access to diagnostic facilities. We present a case of scrub typhus in a 43-year-old woman whose clinical diagnosis was missed by two other physicians whom she approached before visiting us. A detailed history of social environment and general examination was sufficient to arrive at a diagnosis which was confirmed by the presence of IgM antibodies against scrub typhus.

How to cite this article:
Bagavathinathan M, Thangaraj P. Lesson learnt from a missed case of scrub typhus: An interesting case report.J NTR Univ Health Sci 2018;7:298-300

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Bagavathinathan M, Thangaraj P. Lesson learnt from a missed case of scrub typhus: An interesting case report. J NTR Univ Health Sci [serial online] 2018 [cited 2020 May 25 ];7:298-300
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Scrub typhus is caused by Orientia tsutsugamushi, a bacteria which is transmitted to humans by the bite of the larval form of the adult trombiculid mite. The disease is characterized by acute febrile illness, which can involve multiple organ systems and result in significant morbidity and mortality. Around 1 billion people over the world are at risk of developing the infection.[1] In India, scrub typhus has been known for several years and reported in many states starting from Jammu and Kashmir, and Himachal Pradesh in the north, Kerala and Tamil Nadu in the south, Maharashtra in the east, and to Assam in the west.[2] It appears to be a typical neglected tropical disease not only affecting rural populations but also, recently, urban populations.[3] Apart from neglecting the disease, its diagnosis and prevention are also unknown to many.[4] Resurgence of scrub typhus in recent times has been considered as a public health threat in several states of India along with the neighboring countries.[5],[6]

The presence of an eschar of size 5–20 mm at the site of bite of the vector is diagnostic of the disease, but it is present only among 20%–87% of the patients.[7] We here present a case of scrub with typical symptoms and eschar present on the abdomen. The diagnosis was missed by two other physicians before we suspected and diagnosed the patient.

 Case History

A 37-year-old female homemaker belonging to upper middle class from an urban area in Trichy district, Tamil Nadu, presented with sudden onset of high-grade fever (102–104°C) for the past 12 days. Her fever was continuous and associated with chills and rigor. She also complained of generalized body ache and severe headache for the past 5 days. During this period, she visited two other physicians and was started on antibiotics (cefixime and cefpodoxime) along with antipyretics with no improvement. She was tested for routine blood investigation which was within normal limits.

On the first day of her visit at our clinic, she was started empirically on injections gentamycin and cefoperazone and asked to visit after 2 days with blood and urine reports. The observations were as follows: hemoglobin 12.5 g/dL; platelet count 220,000 cells/mm3; erythrocyte sedimentation rate – half-hour, 20 mm and 1 h, 60 mm; malarial parasite – negative, urea 16 mg/dL, creatinine 0.6 mg, Widal negative, and liver function tests were within normal limits. Her urine routine was also normal. She continued to have a high temperature of 102°C on her second visit. During this visit, a detailed history was taken regarding the presence of any scar or rash on any part of her body, following which she replied of a healing lesion on her abdomen that was present around 10 days back. Examination of the scar revealed the presence of eschar of size 7 mm [Figure 1]. On further enquiry about her home surrounding and any insect bite, we found the presence of shrubs and wild plants around her house. Her blood sample was sent for scrub typhus antibody IgM which was found reactive. She was started on tablet azithromycin 500 mg OD for 3 days and capsule doxycycline 100 mg BD for 7 days. Her temperature returned to normal within 2 days and she showed significant improvement.{Figure 1}


Clinical diagnosis of scrub typhus is often missed because of vague symptoms and signs of the illness which are often nonspecific. The nonspecific presentation and also the lack of characteristic eschar in about 40% of patients result in misdiagnosis and underreporting of the disease which is common. Even diagnostic tests are not widely available. Therefore, the precise incidence of the disease is still unknown. Mortality rates among untreated patients can range from 0% to 30%.[8] It is well known that scrub typhus is widely prevalent in many parts of India, but data supporting it are not available.[9]

During the past decade, southern India has witnessed an increase in scrub typhus with outbreaks in winter months. In Tamil Nadu, the most common presentation of the disease is fever with myalgia.[10] Even our case presented in a similar way. Studies published in recent years have also reported cases in north and north-eastern parts of the country.[11],[12],[13]

The presence of eschar is the key to clinical diagnosis which is often missed as the vector bite is painless and the patients do not notice it. A study done on the distribution of eschars among patients in Vellore found that the most common site for its presence was chest and abdomen in females (42.3%) and axilla, groin, and genitalia in males (55.8%).[14] This correlates with our study. Moreover, women are shy to expose their body to the treating physician, and therefore during history-taking, more emphasis on the presence of any abnormal lesion on any body parts should be asked for. Several studies published in the recent years have emphasized the re-emergence of scrub typhus infection and the need for awareness among the treating physician to diagnosis it and give timely treatment.[15],[16],[17] Hence, this study highlights the importance of proper history-taking and clinical examination before asking for blood report. We also stress on the need for social environment history that can also contribute significantly toward the diagnosis of the disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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