Diagnosing scrub typhus: meticulous physical examination is the key.

To cite: Rajasekharan C, Anu J, Neeraj V, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014204695 DESCRIPTION A 50-year-old woman and a 45-year-old man were referred to the internal medicine department with a history of high-grade intermittent fever, headache, myalgia and non-productive cough of 10 days duration. Except for fever, the general examination and physical examination were unremarkable. No rashes or other skin lesions were seen on the exposed parts on routine general examination. The laboratory investigations, including complete blood count and erythrocyte sedimentation rate, were normal; both patients had elevated C reactive protein levels and modest elevation of aspartate aminotransferase and alanine aminotransferase levels. Blood cultures showed no growth. Both patients responded to paracetamol tablets orally with temporary defervescence. A review physical examination of the first patient on the sixth day showed a round to oval plaque with erythematous halo and central haemorrhagic crust on the undersurface of the left breast with no regional adenopathy, suggestive of an eschar (figure 1A) and examination of the second patient revealed an oval plaque with haemorrhagic crust and peripheral collaret with scales suggestive of a healing eschar (figure 1B). IgM scrub was positive in both patients and was confirmed by PCR using the scab specimen at the bite site. Both cases were treated with doxycline 100 mg twice daily and over the days both patients improved with prompt defervescence. Scrub typhus is an acute febrile illness with the characteristics of high fever, headache and rash. The disease is caused by Orientia (formerly Rickettsia) tsutsugamushi. It is a major febrile disease that occurs in south Asian countries during scrub typhus season. Eschar is an important sign for the diagnosis of scrub typhus. It is very difficult to make out rashes in patients on the Indian subcontinent owing to skin colour.