From eschar to diagnosis: A case report on scrub typhus causing multi-organ failure in a returning traveller

Scrub typhus, caused by Orientia tsutsugamushi, is a rickettsial infection transmitted by mite bites, often underdiagnosed in travellers from endemic regions. This case report describes a 65-year-old female with hypertension who developed severe scrub typhus after a trip to Sri Lanka. She presented with fever, myalgia, headache, fatigue and a scabbed lesion. Initial tests showed neutrophilia, lymphocytopenia and elevated liver enzymes. Malaria was ruled out, and empiric treatment with intravenous Tazocin was initiated. On day 5, she developed Clostridium difficile infection, requiring a switch to oral vancomycin. By day 5, her condition worsened with hypoxia, hypotension, oliguria and renal failure. Chest X-ray revealed bilateral infiltrates and subsequently, she was transferred to critical care. Tests showed positive IgM test for O. tsutsugamushi. Oral doxycycline was started, resulting in rapid improvement. PCR confirmed scrub typhus. This case underscores the importance of early diagnosis and treatment with doxycycline in travellers from endemic areas presenting with febrile illness.