Scrub Typhus Mimicking Severe Community-Acquired Pneumonia: A Diagnostic Challenge

A 23-year-old previously healthy female presented with a five-day history of high-grade fever, productive cough, throat pain, and progressive breathlessness. On admission, she was in respiratory distress with severe hypoxia requiring high-flow nasal cannula support. Chest x-ray revealed extensive bilateral lower lobe consolidation, moderate left-sided pleural effusion, and right-sided minimal pleural effusion. Initial empirical treatment with ceftriaxone and azithromycin for community-acquired pneumonia failed to improve her condition. High-resolution computed tomography of the chest confirmed multilobar consolidation, prompting further infectious workup. Serology for scrub typhus was positive, leading to a diagnosis of scrub typhus pneumonia. The patient was transitioned to targeted therapy with doxycycline, resulting in rapid clinical improvement. Oxygenation improved, inflammatory markers declined, and she was successfully weaned off non-invasive ventilation. However, she developed persistent hoarseness, and laryngoscopic evaluation revealed post-infectious laryngitis with reduced vocal cord mobility. The condition was managed conservatively with voice rest and steam inhalation, leading to gradual resolution. She was discharged after 14 days with complete respiratory recovery. Scrub typhus pneumonia typically involves the lower lobes, but multilobar involvement, upper lobe consolidation, and pleural effusion are rare. Delayed diagnosis and the absence of a characteristic eschar can contribute to treatment delays. Early suspicion, serological testing, and initiation of doxycycline are essential for favorable outcomes. Our case highlights the need to consider scrub typhus in patients with severe, atypical pneumonia, particularly in endemic regions.