An unusual site of chigger bite in a patient with scrub typhus

A 70-year-old female farmer was admitted to the hospital because of fever, headache, and diarrhea for 7 days. Hypotension, right-sided pleural effusion with respiratory distress and leukocytosis were noted. She was initially treated as systemic bacterial infection by i.v. administration of ampicillin/sulbactam and amikacin. Because fever persisted in spite of aggressive treatment, a repeat thorough physical examination was done. An eschar was found over the left-sided labium majus and an enlarged lymph node was noted over the left inguinal region. Under the impression of scrub typhus, minocycline was administered. The patient's clinical condition improved dramatically within 3 days. The diagnosis was later confirmed by a serologic test for Rickettsia tsutsugamushi.