Description

A 79-year-old Japanese woman presented to the emergency department with a 4-day history of fever (37–39°C) of unknown origin, headache and loss of appetite. She denied respiratory distress and other symptoms; her SpO₂ was 88% on room air. Two weeks before presentation, she travelled to a mountain in Japan to collect edible plants.

On physical examination, purple-coloured, non-pruritic eruptions were observed on her face, extremities and trunk (figure 1). An eschar was observed in the left lower extremity (figure 2). Laboratory tests revealed the following: platelet count 70 000/μL; aspartate aminotransferase level 144 U/L and alanine aminotransferase level 444 U/L. Serological tests revealed high Orientia tsutsugamushi IgG and IgM antibody titres. She was diagnosed with scrub typhus (tsutsugamushi disease) and was started on 200 mg of minocycline. After 2 weeks of the treatment, her symptoms resolved and the eruptions disappeared. She was discharged without complication.

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Figure 1

Purple-coloured, non-pruritic eruptions on the trunk.

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Figure 2

An eschar in the left lower extremity.

Scrub typhus, also known as tsutsugamushi disease, is an acute lethal infectious disease caused by O. tsutsugamushi. It is endemic to the Asian Pacific area. Common clinical manifestations of the disease are febrile, headache and rash.1 Diagnosis is difficult because many patients present as fever of unknown origin. Evidence of an eschar is the only clue for the diagnosis, while serological methods play limited roles in making a decision on whether or not treatment should be initiated.2 ,3