Beyond Fever: A Case Series Highlighting the Varied Clinical Manifestations of Scrub Typhus

Abstract

Background: Scrub typhus is an important infectious disease in India and can affect multiple organ systems. Although fever and eschar are useful clinical clues, they may be absent, leading to diagnostic challenges and potential delays in treatment. This case series was undertaken to highlight the varied presentations of scrub typhus and emphasise the need to consider it in patients with unexplained multisystem illness, even in the absence of classical features. Aim: To report a case series of six patients with varied manifestations of scrub typhus affecting different organ systems. Presentation of the Case: We describe six patients with diverse manifestations of scrub typhus, including meningoencephalitis, pneumonitis, acute kidney injury, multiorgan dysfunction syndrome with jaundice mimicking obstructive jaundice, a cholangitis-like presentation, and severe encephalopathy without fever. Serum scrub typhus IgM was positive in all patients, with CSF IgM also positive in the patient with meningoencephalitis. An eschar was identified in two patients, while two patients presented without fever. In patients with hepatobiliary involvement, marked jaundice and elevated liver enzymes were observed despite the absence of biliary obstruction on imaging. Renal involvement ranged from mild dysfunction to severe AKI, with a maximum creatinine level of 6.5 mg/dL. All patients received doxycycline and azithromycin for 7–14 days and showed gradual clinical improvement. Conclusion: This case series highlights the diverse manifestations of scrub typhus, with neurological, respiratory, renal, hepatic, and multiorgan involvement. The absence of fever or an eschar should not exclude scrub typhus, particularly in endemic regions, as such presentations may mimic other infectious and systemic conditions. A high index of suspicion, careful clinical examination, and appropriate serological testing are essential for diagnosis. All six patients showed gradual clinical recovery following appropriate anti-rickettsial therapy. These findings emphasise the importance of considering scrub typhus in patients with unexplained multisystem illness in endemic areas.