[Case of imported scrub typhus contracted in Myanmar]

Scrub typhus is widespread in rural south and southeastern Asia and the western Pacific. The scrub typhus incidence is the highest among vector-borne diseases in Japan, but imported cases are extremely rare. A 49-year-old man admitted for persistent fever, headache, and rash after returning from Myanmar had been exposed to mosquito and tick bites while doing a 12-day forest inventory in Myanmar. On admission, he had a generalized maculopapular rash but no apparent eschars characteristic of scrub typhus. Blood examination and abdominal ultrasonography showed elevated liver enzymes, thrombocytopenia, and hepatosplenomegaly. Repeated blood smears and blood cultures were negative for malaria infection and bacteremia. Dengue fever was denied by both PCR and serology. The patient deteriorated on the ninth day and suffered complications of rhabdomyolysis, pneumonia, and enteritis. Based on a tentative diagnosis of typhoid fever or rickettiosis, we administratered ceftriaxone and minocycline, which dramatically reduced clinical signs and symptoms. After discharge on day 19, immunofluorescence assay showed significantly increased antibodies for Orienta tsutsugamushi serotype Gilliam, first discovered in Myanmar. All serological results were negative for other rickettioses, leptospirosis and Q fever. Given the many travelers from Japan visiting endemic scrub typhus areas, we must recognize cases of imported scrub typhus among those travelers with fever and rash returning from endemic areas.