Diagnosing scrub typhus: meticulous physical examination is the key

A 50-year-old woman and a 45-year-old man were referred to the internal medicine department with a history of high-grade intermittent fever, headache, myalgia and non-productive cough of 10 days duration. Except for fever, the general examination and physical examination were unremarkable. No rashes or other skin lesions were seen on the exposed parts on routine general examination. The laboratory investigations, including complete blood count and erythrocyte sedimentation rate, were normal; both patients had elevated C reactive protein levels and modest elevation of aspartate aminotransferase and alanine aminotransferase levels. Blood cultures showed no growth. Both patients responded to paracetamol tablets orally with temporary defervescence. A review physical examination of the first patient on the sixth day showed a round to oval plaque with erythematous halo and central haemorrhagic crust on the undersurface of …