This document describes the case of a 51-year-old female who presented with fever, chills, nausea, and weakness. Initial workup revealed normal vital signs and lab tests. Further examination uncovered an eschar on her abdomen, leading to a diagnosis of scrub typhus. Scrub typhus is an acute febrile illness caused by Orientia tsutsugamuchi transmitted by mites. It is characterized by eschar formation and disseminated rash. The patient was started on doxycycline treatment. Thorough history and examination are important to identify atypical infections like scrub typhus in patients presenting with undifferentiated fever.

1. An interesting fever..
Lee Chiang Sheng

3. Mdm B, 51 years old Ibanese
• Known history of hypertension under
treatment
• Previously well.
• Was admitted on the 20th September with the
chief complain
– fever, chills, rigor x 1/52

4. • Fever started after returning from work in the afternoon.
• Was associated with
– nausea and vomiting x 1 episode (non blood/billous stained,
only food particles; non projectile),
– generalized body weakness,
– photophobia,
– headache (mainly frontal area with ?radiation to the neck)
– LOA
• No LOW, night sweats, no SOB/cough/chest pain, weakness
of the limbs, seizure, visual changes, syncopal attack, no
dysuria/hematuria/frequency, no rash.
No PV discharge/ bleed
• Father claimed that ever since she was sick, she has
become withdrawn from her family; ?personality change.
• No reversal of sleeping pattern.
• Has not returned to work ever since.

5. Past Medical History
• Hypertension
– Taking T. Methyldopa 250mg TDS
– Regular follow up at community clinic
Past Surgical History
• History of appendicectomy many years back.

6. Family History
• Married with 5 children.
• Husband passed away d/t UGIB.
• No family members with fever.

7. Social History
• Denies any recent sexual contact/partners
• Social drinker (drinks rice wine)
• Non-smoker/ non IVDU

8. On Examination
• GCS full, Pink, conscious but slightly drowsy
looking lady, not on any oxygen therapy/IV drip,
not breathless with a RR of around 20 bpm, not in
pain/cyanosed.
• Vitals:
– BP 116/70,
– Temp 38.3C,
– RR 20 bpm,
– SpO2 99% under room air

9. • Hand: Warm and sweaty hands. No clubbing,
CRT <2s, no splinter hemorrhages, no nail fold
vasculitis, no Osler nodes/Janeway lesions.
• Pulse: 80 bpm, regular rhythm, good volume,
equal on both sides, good caliber
• Arm: No injection marks seen, no bruising

10. • Face: conjunctival pallor, no scleral icterus,
cornea arcus
• Dental hygiene: good; tongue: moist
• Neck: no regional lymphadenopathy

11. • Praecordium: DRNM; good air entry with
vesicular breath sounds/no adventitious
sound
• Abdomen: not distended, Soft non tender; no
hepato/splenomegaly; kidney not ballotable,
bowel sounds present; Murphy’s punch –ve
• Lower limb: No swelling/tender calf.

12. • Neuro Exam: essentially normal with no focal
neurological deficits; no cranial nerve palsies,
Neck stiffness.

13. Observation
Chart
High grade
fever!
Initial Management:
She was started Tab
paracetamol and IV
Ceftriaxone on the first day of
admission. But fever still
persist..What could it be?

14. WAIT! Don’t proceed to the
next slide yet. Reflect
through the case and think..
Any further history and examination you’d like
to do? What is your differential diagnosis? And
what investigations will you order?

15. Further Social History..
• No history of travel/ jungle trekking/
swimming in river
• Works as a farmer in a paddy field (owned by
the family)
• Lives in a village, near a rubber plantation.
*Inguinal region:
++ inguinal lymphadenopathy

16. Ddx?
• Bacterial Meningitis,
• viral encephalitis,
• Malaria
• Dengue
• Pneumonia (typical vs atypical),
• TB

17. Basic blood investigations
Normochromic
normocytic

18. Other blood Ix
• Hep B/C & HIV; RPR – negative
• BFMP x1 negative; x2 and x3 still pending
• Urine FEME:
– Specific gravity: 1.02
– pH 6.0
– Leu –ve
– Nit –ve
– Pn 1+
– Glu –ve
– Ket 3+
– Urobil –ve
– Bil –ve
– Blood 1+
– Color Yellow

19. • ECG: normal sinus rhythm with no ischemic
changes
• ECHO: essentially normal findings; EF 68%, no
regional wall motion abnormality, no
apical/mural thrombus

20. Chest
Radiograph
• Normal

21. Essentially
normal

22. CSF
• Cell count: 2 (all lymphocytes)
• CSF protein: 0.44 (normal <0.4~0.45)
• CSF glucose (3.0); serum glucose 5.3 (ratio
0.57)
• Gram stain – no organism seen
• culture – no growth

23. So, what do you think you’ve missed?
Fortunately, this lady was seen by one of the
physician on call and he meticulously examined
her and found something unusual on her
abdomen..
Do you know what is it?

24. Image taken with permission from the patient

25. Does it resemble her lesion?

26. • ESCHAR/ “Tache noire” measuring approx.
1cm x 3cm was seen over the right lumbar
region of the anterior abdomen!!
• Patient claimed this was present around a few
days before the symptoms and it was itchy but
painless. So the diagnosis is?

27. Scrub Typhus
• An acute febrile illness caused by Orientia tsutsugamuchi
(intracellular gram –ve bacteria) transmitted via larval stage of
trombiculid mites from rodent to human, an accidental host.

28. • The initial lesion of scrub typhus is a papule that
develops at the site of the inoculation and it
subsequently forms an eschar. Approximately 1 to 2
weeks after the development of the initial lesion, an
abrupt onset of high fever, headache, and
disseminated papulomacular skin rash develops.
• The diagnosis of scrub typhus has been based on the
assessment of the titer of antibody in serum samples
that are obtained during the acute and convalescent
phases of the illness. However, it takes several weeks
to confirm the diagnosis by serologic testing to
establish a fourfold or greater titer increase.

29. Distribution of Eschar
• The reported incidence of eschar in most studies
varies from 46-85%. Irons et al reported that
eschar is usually located in warm, damp areas
where pressure from clothing occurs.
• Thus perineum, inguinal region, axilla,
underneath the breasts are common areas.

30. Management
• Diagnosis of scrub typhus is mainly clinical
especially in patients with characteristic
symptoms and signs.
• Antibiotic therapy should begin promptly
– Doxycycline and chloramphenicol are commonly
used.
– In Doxycycline resistant scrub typhus,
azithromycin and rifampicin have been effective.
– Diagnosis can be confirmed via lab tests (usually
>1 week needed)

31. Complication
Since it is a vasculitic process, it is capable of
causing multiple organ involvement.
• Renal: azotemia/proteinuria
• Hematologic: leukopenia, leukocytosis,
thrombocytopenia
• Hepatic: elevated liver enzymes
• Metabolic: hypoalbuminemia/electrolyte abnormalities
(e.g. hypoNa)
• Heart: myocarditis/pericarditis
• CNS: aseptic meningitis/ meningoencephalitis

32. Progress..
• She was started on T. Doxycycline 100mg BD x 5/7.

33. Learning Pearls
• Always enquire about patient’s SOCIAL
HISTORY as it may give a hint to the
underlying problem!
• Always be meticulous and thorough in your
examination especially in patients with fever
without a known source.

34. Thank you and Happy New Year!