Atypical eschar: An unusual cutaneous manifestation of scrub typhus.

chigger fever, is a mite-transmitted zoonosis caused by Orientia tsutsugamushi. The vector is the larval stage (chigger) of the trombiculid mite (Leptotrombidium deliense and several other Leptotrombidium spp). The mites and the rodents that carry them serve as the major reservoirs1. Scrub typhus is widely prevalent in the ‘tsutsugamushi triangle’ region of the world spanning the Indian subcontinent to eastern Asia and the western Pacific rim (Japan, Korea, India, Pakistan, Taiwan, Southeast Asia and Australia)1-2. The clinical features include fever, myalgia, headache, rash, and a pathognomonic eschar formed by the bite of chigger mite that inoculates the causative agent of scrub typhus Orientia tsutsugamushi2. The local reaction at the site of chigger bite occurs as a painless papule which subsequently undergoes central necrosis with formation of an eschar. Regional lymphadenopathy, with development of large and tender lymph nodes, occurs at the site of the bite and may lead to generalized lymphadenopathy3. The clinical diagnosis is difficult as the symptoms are similar to other febrile illnesses such as dengue, typhoid, leptospirosis etc. An eschar, if present, narrows down the provisional diagnosis towards scrub typhus3. The nonspecific presentation and lack of the characteristic eschar in 40% of patients leads to many undiagnosed cases of scrub typhus4. Here, we report four cases of scrub typhus, hailing from the rural areas of south India, who presented with unusual skin manifestation of scrub typhus which helped in the diagnosis of the condition. Similar presentation has not been mentioned in the literature previously.