Large-Vessel Pseudoaneurysms as a Vascular Complication of Scrub Typhus in an Immunosuppressed Patient

Diagnosing febrile illnesses in children from tropical regions poses significant clinical challenges due to overlapping symptoms of endemic infections such as malaria, dengue and scrub typhus. Although coinfections are uncommon, they can complicate clinical management and delay targeted therapy. We report the case of a 5-year-old boy of Odisha origin, living in Tamil Nadu, who presented with a seven-day history of high-grade, intermittent fever. Initial clinical and laboratory investigations revealed severe anaemia and thrombocytopenia. Rapid diagnostic tests confirmed co-infection with Plasmodium falciparum, P. vivax and dengue virus. The child received antimalarial drugs and supportive therapy. However, there was limited clinical improvement. Although the characteristic eschar typically associated with scrub typhus was absent, the persistent febrile course and inadequate response to treatment raised clinical suspicion of an additional co-infection. Considering the regional endemicity of scrub typhus, IgM serology was performed and tested positive. The patient was then treated with a combination of antimalarials, doxycycline, and supportive measures, including blood transfusion for anaemia. Marked clinical and haematological improvement occurred within days of initiating the revised treatment plan. This case underscores the need to consider co-infections in paediatric patients presenting with prolonged fever in endemic regions. Early clinical suspicion, prompt diagnostic workup and appropriate therapy are essential for achieving favourable outcomes in such challenging scenarios.

Background: Scrub typhus is a common aetiology for an acute undifferentiated fever among children. Early recognition and prompt management help to reduce morbidity and mortality.Methods: All children who visited our pediatric out-patient department between January 2016 and February 2018, admitted with clinical suspicion of scrub typhus and having positive serum IgM by ELISA were included in the study.Results: A total of 83 cases were enrolled during the study period. Of these 55 were boys and 28 girls. The average age of presentation was seven years, and the youngest was just five months old. Majority of these patients were from rural areas (86%). Roughly, two-thirds (77%) of the study group practiced open defecation. A maximum number of cases (65;78.3%) were reported during monsoon season (between September and January).Prolonged fever (100%), gastrointestinal symptoms (76%) such as vomiting, diarrhoea and abdominal pain, lymphadenopathy (96%) and hepatosplenomegaly (61%) were common signs and symptoms of pediatric scrub typhus. Only six patients had severe illnesses. The diagnosis was based on the positive serum IgM for scrub typhus. All the patients were IgM positive. Out of these 83 patients, eschar was seen in 50 (60%) patients. Weil Felix test was positive in 15 cases out of 33 tested cases. Six children had co-infection with 2 cases of malaria and four dengue fever cases.Conclusions: Scrub typhus is one of the common causes for acute undifferentiated fever among children. A high index of clinical suspicion and a lookout for an eschar shall facilitate an early diagnosis of scrub typhus.

Eschar in scrub typhus aids in early diagnosis and institution of appropriate therapy; however, the eschar positivity rates vary greatly in endemic regions. Multiple eschars in scrub typhus are a rare presentation. Our patient presented with fever and multiple eschars and was empirically started on doxycycline. Nested polymerase chain reaction from all the four eschars and from EDTA blood were positive for 56-kDa type-specific antigen which is specific for Orientia tsutsugamushi The patient recovered completely after 7 days of antibiotic treatment. He was from an area where scrub typhus was not observed previously. An eschar in an acute febrile patient from the "tsutsugamushi triangle" is a valuable sign in scrub typhus diagnosis. A search for multiple eschars in scrub typhus must be made by clinicians.

The clinical spectrum of scrub typhus varies widely, from mild febrile illness to life-threatening complications, often resulting in clinical dilemmas. Scrub typhus may be overlooked in classical community-acquired respiratory infections. This report presents a case of elderly male whose symptoms and radiological findings strongly suggested multi-lobar community-acquired pneumonia. The diagnosis became clear on day 4 when an abdominal Eschar was noted, prompting serological confirmation of scrub typhus. The subsequent treatment modification led to the patient’s full clinical recovery. This case underscores the need to consider scrub typhus as a potential cause of pneumonia, especially in the endemic regions. It is also important to note that empirical and conventional beta-lactam antibiotics for the treatment of pneumonia might not benefit scrub typhus pneumonia. Given the varied manifestations of scrub typhus and absence of the pathognomonic eschar in a significant number of patients, its diagnosis requires a high degree of suspicion.

Central nervous system (CNS) involvement in scrub typhus is seen in up to a quarter of patients. However, the literature on cerebrospinal fluid (CSF) analysis and outcome in meningitis/meningo-encephalitis due to scrub typhus is scant. This retrospective study included patients who were admitted to a medical college hospital with scrub typhus meningitis/meningo-encephalitis between 2005 and 2011. The clinical and laboratory profile, details of CSF analysis and outcome were documented. The study included 189 patients with meningitis/meningo-encephalitis due to scrub typhus. The mean age of the patients was 41 ± 4 years. The mean duration of fever before presentation was 9.4 ± 3 days. The common presenting complaints were headache (64.2%), nausea/vomiting (60%), altered sensorium (53.7%) and seizures (22.1%). The presence of an eschar was documented in 27.5% of the patients. The mean CSF white blood count was 80 cells/cu mm (range: 5-740). There was a clear lymphocyte predominance (mean 87.6%). The mean CSF protein level was 105 mg% (range: 13-640). The mean CSF sugar level was 63.9 mg% (range 25-350), and was less than 40 mg% in 11.1% of the cases. The case fatality rate was 5.8% (11/189). Univariate analysis showed the presence of an eschar (15.4% vs 2.2%; Odds Ratio [OR]: 8.1) and altered sensorium (9.8% vs 1.1%; OR: 9.2) to be significant predictors of mortality. In endemic regions, scrub typhus should be considered in the differential diagnosis of aseptic meningitis. Modest elevation of cells in the CSF with lymphocytic pleocytosis and multi-organ involvement may indicate scrub typhus meningitis/meningo-encephalitis.

Rationale: Longitudinally extensive transverse myelitis (LETM) is a rare inflammatory demyelinating disease predominantly associated with autoimmune and inflammatory disorders. Scrub typhus can cause a variety of neurological complications, which may result in poor recovery and long-term disability. This report reveals a rare linkage between LETM and scrub typhus. Patient concerns: A 24-year-old female presented with a history of fever for 10 days associated with progressive quadriparesis. Physical examination revealed bilateral lower limb weakness (grade 0/5) and bilateral upper limb weakness (grade 2/5) with reduced sensation below the T3 dermatome. Diagnosis: Scrub typhus presenting with longitudinally extensive transverse myelitis. Interventions: Steroid pulse therapy with antibiotics supported by early intensive rehabilitation. Outcomes: Complete recovery was achieved. Lessons: This case report highlights the importance of considering scrub typhus as a potential cause of LETM in endemic regions, particularly in patients presenting with febrile illness and neurological symptoms.

BackgroundScrub typhus can present with atypical signs and symptoms such as those of acute kidney injury, gastroenteritis, pneumonitis, and acute respiratory distress syndrome. Meningitis, encephalitis, and hepatic dysfunction have also been reported, particularly in severe cases with multisystem involvement. Scrub typhus has never been reported in the literature to cause urinary tract infections (UTIs) which includes cystitis and pyelonephritis.Case presentationA 45-year old male presenting to the outpatient unit with fever, right flank pain, and burning micturition for three days was initially treated for UTI. However, he returned to the hospital on the fourth day of illness with persistent symptoms. He was hospitalized, with intravenous (IV) ceftriaxone. Computerized tomography scan of his abdomen-pelvis showed features of acute pyelonephritis, so his antibiotics were upgraded to meropenem and teicoplanin. Despite this, the patient’s condition deteriorated. Laboratory investigations showed multisystem involvement: decreasing platelets, raised creatinine, and deranged liver panel. As Kathmandu was hit by dengue epidemic during the patient’s hospitalization, on the seventh day of his illness, blood samples were sent for tropical fever investigation. All tests came out negative except for scrub typhus—IgM antibodies positive on rapid diagnostic test. The patient’s symptoms subsided after 48 h of starting doxycycline and he became fully asymptomatic four days later. Fever did not recur even after discontinuing other IV antibiotics, favoring scrub typhus disease rather than systemic bacterial sepsis.ConclusionsScrub typhus is an emerging infectious disease of Nepal. Therefore, every unexplained fever cases (irrespective of clinical presentation) should be evaluated for potential Rickettsiosis. Moreover, for cases with acute pyelonephritis, atypical causative agents should be investigated, for example scrub typhus in this case.

Scrub typhus is an endemic zoonosis caused by Orientia tsutsugamushi, presenting with a range of neurological manifestations. Despite its high prevalence in endemic areas and clinical relevance, a systematic description of the neuroimaging patterns remains sparse. This study emphasizes the imaging spectrum with clinic-radiological correlations of neurological manifestations of scrub typhus across three tertiary care centers in South India. This retrospective multicenter study included 55 patients with neurological symptoms and serologically confirmed scrub typhus, who underwent MRI between January 2020 and March 2025. Two experienced neuroradiologists reviewed the imaging for patterns, along with available CT imaging. Detailed demographic, clinical, and laboratory data were studied from health records. MRI abnormalities were found in 46 of the 55 patients (83.6%). Leptomeningeal enhancement was the most common observation (49.1%), primarily affecting the parieto-occipital and cerebellar sulci, and was best appreciated on post-contrast FLAIR. Encephalitic changes were seen in 16.4% with heterogeneous patterns including cortical, basal ganglia, thalamic, hippocampal, ADEM-like, and ANE-like involvement. 12.7% had cerebellitis, 9.1% had multifocal restricted diffusion, 7.3% had white matter hyperintensities, 7.3% had rhombencephalitis, and 5.5% had myelitis. Lacunar/cerebellar infarcts (5.5%), cerebral venous thrombosis (3.6%), and micro haemorrhages (9.1%) were among the vascular manifestations. Cranial nerves were involved in 5.5%. 20/28 patients (71.4%) had CT abnormalities, with diffuse cerebral edema being the most prevalent. Leptomeningeal enhancement frequently occurred with encephalitis and cerebellitis, while myelitis occurred with rhombencephalitis. ASL was performed in 6 patients, demonstrating hyperperfusion in cases of encephalitis and cerebellitis. Follow-up imaging in 7 patients revealed complete resolution of leptomeningeal and cerebellar enhancement, with variable evolution of encephalopathic changes, ranging from complete resolution to gliosis and volume loss. Scrub typhus neuroinfection demonstrates a broad imaging spectrum, most frequently leptomeningeal enhancement with characteristic parieto-occipital and cerebellar predilection. MRI remains the modality of choice, though CT retains diagnostic value in acute or resource-limited settings. Recognition of these patterns in febrile patients from endemic regions can expedite diagnosis and treatment, preventing neurological sequelae.

Prolonged Fever, Travel, and the Changing Examination in an 8-year-old Girl.

Scrub typhus is an acute, febrile illness, caused by the bacterium Orientia tsutsugamushi, that affects millions annually in the endemic Asia-Pacific region. In untreated cases, the case-fatality rates range from 6% to 35%. In Bhutan, there was a probable outbreak in Gedu in 2009, which resulted in heightened awareness of the disease. Nevertheless, information on scrub typhus in Bhutan is limited and scattered and the epidemiology has yet to be established. To report the current picture of scrub typhus in Bhutan, this review gathered data from scholarly databases, surveillance reports, the Annual health bulletin, research publications and laboratory test reports from hospitals. The weight of evidence indicates an increasing burden of scrub typhus since the Gedu incident, coupled with increased awareness and testing. Another outbreak in a rural primary school in 2014 resulted in two deaths. More hospitals now have testing facilities and laboratory-confirmed cases have been increasing since 2009, with seasonal trends. This review highlights the need for in-depth surveillance and reporting, increased awareness among health-care workers, and initiation of prevention and control programmes in the country.

Background: Scrub typhus is a re-emerging zoonotic infection in India with significant morbidity and mortality due to delayed diagnosis and complications. Methods: An observational cross-sectional study was conducted over 18 months at Sree Balaji Medical College & Hospital, Chennai. Ninety-three adult patients with confirmed scrub typhus (IgM ELISA and/or eschar) were enrolled. Sociodemographic, clinical, and laboratory data were collected. Associations with complications and outcomes were analyzed using chi-square and t-tests. Results: Most patients were male (71%) and from rural areas (78.5%). The predominant age groups were 20–29 (22.6%) and 40–49 (21.5%) years. Fever (100%), myalgia (76.3%), and headache (63.4%) were common. Eschar was seen in 20.4%. Complications occurred in 52.7%, mainly renal (14.0%), respiratory (11.8%), and neurological (5.4%). Multi-organ dysfunction syndrome (MODS) was present in 5.4% and was significantly associated with mortality (p < 0.01). The overall case fatality rate was 6.5%. Risk factors included outdoor exposure (95.7%), rodent presence (93.5%), and vegetation exposure (86.0%). Conclusion: Scrub typhus remains a major health challenge in endemic regions. Early recognition, timely treatment, and clinician awareness are crucial to prevent severe complications. MODS is a key predictor of mortality. Strengthening diagnostic capacity and vector control measures in rural communities is essential.

This case series highlights four pediatric patients with coinfection of dengue fever and scrub typhus, presenting at Patan Hospital. Dengue fever is caused by flavivirus transmitted by Aedes mosquitoes, and scrub typhus is caused by Orientia tsutsugamushi transmitted by Leptotrombidium mites, which share overlapping symptoms such as fever, headache, and abdominal pain, complicating the diagnosis. The cases were from different geographical regions of Nepal with varied presentation: from febrile illness to severe manifestations like meningoencephalitis and raised intracranial pressure. Two patients presented with hepatosplenomegaly, one with severe rash, and another with pneumonia-like symptoms. Laboratory findings confirmed coinfection, and management included IV antibiotics, antipyretics, and supportive management. Complications such as thrombocytopenia, transaminitis, and allergic reactions required interventions. This case series highlights the importance of early suspicion and treatment of coinfection to reduce prolonged hospitalization and prevent end-organ dysfunction, and mortality, especially in endemic regions.

Background: Pediatric tropical fevers represent a significant public health problem in our country. Multiple viral, parasitic and bacterial pathogens are responsible for tropical diseases in endemic regions. The study aimed to assess the clinical and etiological profile of tropical fever cases presenting to our tertiary care hospital in the northern part of West Bengal. Materials and methods: This observational, cross-sectional study was done in hospitalized children after obtaining approval from the Institutional Ethics Committee. Duration was 1 year from December 2022 to November 2023. Participants satisfied the inclusion criteria and confirmed positive on laboratory investigations were enrolled. Written informed consent from parents was obtained. Results: A total of 100 patients were finally enrolled for analysis. Mono infections were present in 78% patients, and 22% patients had more than one concurrent infections. The causes of tropical fever included dengue (59%), scrub typhus (50%), enteric fever (7%), malaria (4%), and other infections. Clinical features included vomiting (92%), abdominal pain (82%) pallor (76%), and rash (58%) and others manifestations. Children aged 5-12 years comprised 62% and males were 60% in our study. Survival rate was (97%) and mortality rate was 3%. Conclusion: Dengue and scrub typhus emerged as the major contributors to pediatric tropical fever in this study. Early identification and targeted management based on regional epidemiological pattern can reduce adverse outcome. Further research on a large scale is essential to validate and generalize our findings. Keywords: tropical fever; clinical and etiological profile; children; eastern India

Background: Mycobacterium chelonae is an atypical "fast-growing Mycobacteria" that is a rare cause of human infection. There have been several reports of cutaneous infection among immunosuppressed patients, as well as in immunocompetent individuals following trauma. Most cases to date seem to have occurred among renal transplant recipients, raising the possibility that there is something inherent to the renal transplant patient that increases their susceptibility more than other immunocompromised patients. Objective: The differential diagnosis of subcutaneous nodules distributed in a sporotrichoid pattern is extensive, particularly in an immunocompromised host. Although several cases of cutaneous M. chelonae abscessus infection have been reported among both immunosuppressed and immunocompetent patients, the clinical presentation has varied, and few cases have reported the appearance of lesions in a sporotrichoid pattern. We present a case of a renal transplant patient with a reported history of trauma to the lower extremities, who presents with subcutaneous nodules distributed in a sporotrichoid pattern. The patient is found to have M. chelonae abscessus infection, fails several treatment regimens, and presents with a recurrence. The literature of M. chelonae infection is reviewed, and the various treatment options are discussed. Methods: An initial skin biopsy was stained with Hematoxylin and Eosin and revealed deep dermal abscesses with acid-fast bacilli in clusters. The culture became positive for Mycobacterium chelonae abscesses in four days and was found to be sensitive to multiple antibiotics. The patient underwent surgical excision of 14 nodules, which revealed findings consistent with the skin biopsy, and was subsequently treated with the appropriate antibiotics. Results: Despite treatment with a full course of an organism-sensitive antibiotic regimen, the patient returned with persistent and recurrent nodules six weeks later. The patient was then treated as an inpatient with a seven-week course of intravenous antibiotics and was discharged home on a combined intravenous and oral regimen. Conclusion: Although M. chelonae abscessus is an extremely rare cause of infection among humans, there seems to be a predominance of cases reported among renal transplant patients. The explanation for this is not entirely clear; however, the organism must be considered as a cause of infection in any renal transplant recipient who presents with subcutaneous nodules. Eradication of the organism presents a tremendous challenge to the clinician, and, as presented here, even with appropriate antibiotics, there is a high rate of recurrence.

Mycobacterium chelonae is an atypical "fast-growing Mycobacteria" that is a rare cause of human infection. There have been several reports of cutaneous infection among immunosuppressed patients, as well as in immunocompetent individuals following trauma. Most cases to date seem to have occurred among renal transplant recipients, raising the possibility that there is something inherent to the renal transplant patient that increases their susceptibility more than other immunocompromised patients. The differential diagnosis of subcutaneous nodules distributed in a sporotrichoid pattern is extensive, particularly in an immunocompromised host. Although several cases of cutaneous M. chelonae abscessus infection have been reported among both immunosuppressed and immunocompetent patients, the clinical presentation has varied, and few cases have reported the appearance of lesions in a sporotrichoid pattern. We present a case of a renal transplant patient with a reported history of trauma to the lower extremities, who presents with subcutaneous nodules distributed in a sporotrichoid pattern. The patient is found to have M. chelonae abscessus infection, fails several treatment regimens, and presents with a recurrence. The literature of M. chelonae infection is reviewed, and the various treatment options are discussed. An initial skin biopsy was stained with Hematoxylin and Eosin and revealed deep dermal abscesses with acid-fast bacilli in clusters. The culture became positive for Mycobacterium chelonae abscesses in four days and was found to be sensitive to multiple antibiotics. The patient underwent surgical excision of 14 nodules, which revealed findings consistent with the skin biopsy, and was subsequently treated with the appropriate antibiotics. Despite treatment with a full course of an organism-sensitive antibiotic regimen, the patient returned with persistent and recurrent nodules six weeks later. The patient was then treated as an inpatient with a seven-week course of intravenous antibiotics and was discharged home on a combined intravenous and oral regimen. Although M. chelonae abscessus is an extremely rare cause of infection among humans, there seems to be a predominance of cases reported among renal transplant patients. The explanation for this is not entirely clear; however, the organism must be considered as a cause of infection in any renal transplant recipient who presents with subcutaneous nodules. Eradication of the organism presents a tremendous challenge to the clinician, and, as presented here, even with appropriate antibiotics, there is a high rate of recurrence.