Scrub typhus (Tsutsugamushi disease) in a patient presenting with hemophagocytic syndrome

Scrub typhus is a mite-borne infectious disease caused by Orientia tsutsugamushi, which is found mainly in East and Southeast Asia and in Australia. The disease presents with a variety of non-specific symptoms, including fever, headache, cough, myalgia, and rash. Delay in starting appropriate antimicrobial therapy may lead to serious complications and even death. We report the case of an 84-year-old Japanese patient with scrub typhus who developed hemophagocytic syndrome (HPS) and was successfully treated with minocycline in addition to corticosteroids. A pathognomonic skin ulcer on her right buttock, which was initially covered with black eschar, prompted us to consider the possibility of scrub typhus. Blood polymerase chain reaction and antibody assays confirmed the diagnosis. Scrub typhus must be considered as one of the underlying diseases that may cause HPS in patients living in the Asia-Pacific region and in those who have recently returned from endemic areas.