Scrub typhus in a returning expatriate from the Middle East: A diagnostic challenge

A 52-year-old male, residing in the Middle East, presented with a history of four days of fever, chills, vomiting, and profound fatigue. His symptoms persisted despite initial treatment from abroad with broad-spectrum antibiotics, and he returned to Kerala, South India, where he was hospitalised. On examination, he was febrile but hemodynamically stable, and no eschar was noted. Laboratory investigations showed elevated inflammatory markers, mild transaminitis, hyponatremia, and hypokalaemia. Tests for dengue, malaria, leptospirosis, and viral hepatitis were negative, while Scrub typhus IgM ELISA was strongly positive. Treatment with doxycycline led to marked clinical improvement within three days. This case highlights the challenge in diagnosing scrub typhus in patients from traditionally non-endemic regions and the need for a high index of clinical suspicion.