Background & objectives: Scrub typhus is a neglected tropical disease common in Asia and Africa. It usually presents with non-specific symptoms like fever, rashes, and lymphadenopathy. It has a varying range of clinical picture that often leads to misdiagnosis and initiation of non-specific treatment. This disease is thus associated with high morbidity and mortality. We aim to highlight the uncommon presentations of this common disease to create awareness regarding the unusual presentations of scrub typhus. Methods: This prospective study was performed over a period of two months enrolling eleven adult patients with serological evidence of anti-scrub typhus IgM antibodies. Results: All enrolled 11 cases [5 males (45.5%) and 6 females (54.5%)] were positive for anti-ST IgM antibodies and negative for other tested microbial agents. 7/11 (63.6%) patients were admitted with a clinical diagnosis of acute encephalitis syndrome (AES as per standard WHO definition), 3/11 (27.3%) patients presented with jaundice and 1/11 (9.1%) patients presented with rashes. Two out of 7 (28.6%) AES cases had developed peripheral gangrene of extremities. Interpretation & conclusion: Scrub typhus is a common tropical disease that can have various unusual clinical presentations like meningoencephalitis, vasculitis, acute kidney injury, jaundice, MODS. It closely mimics other infective etiologies making its diagnosis difficult. A high index of suspicion and clinical awareness is required in clinical practice to identify the different presentations of this disease so that early treatment can be initiated to reduce morbidity and mortality associated with this disease.

Unusual clinical presentations of scrub typhus, a neglected tropical disease: A case series from north India

Aims: Infection is a major trigger for both Lupus flare and Macrophage activation syndrome. Scrub typhus infection associated with lupus flare or MAS has been very rarely reported. We report a case of scrub typhus-induced MAS along with a flare of disease activity in a neuropsychiatric lupus patient presenting after discontinuation of medications. 
Presentation of Case: 13-year-old girl, a known case of neuropsychiatric lupus with lupus nephritis, on immunosuppressant for the last 1 year had stopped all medications for 3 months. She had presented with a fever and altered sensorium. Based on clinical and laboratory investigations, a diagnosis of scrub typhus-induced macrophage activation syndrome with a flare of lupus disease activity was made and the patient was treated with injection doxycycline and glucocorticoids. There was rapid clinical improvement with treatment. 
Discussion: The case emphasizes the importance of identifying the exact trigger behind the deterioration of a patient with lupus and its therapeutic implications. An infection alone requires antibiotics only, flare without infection requires up titrating immunosuppressants but the presence of life-threatening complications like MAS along with infection requires prompt treatment of both facets simultaneously. 
Conclusion:  Scrub typhus infection should be ruled out apart from other common infections in any patient with lupus flare or MAS.

Scrub Typhus-Induced Macrophage Activation Syndrome with Flare of Systemic Lupus Erythematosus: A Rare Case Report

Hemophagocytic lymphohistiocytosis (HLH) is a rare but aggressive and potentially fatal condition characterized by excessive immune activation. It can occur as primary/ familial and secondary/sporadic/ acquired form. Infections can play a role as triggers in the secondary form of HLH. A case of Hemophagocytic lymphohistiocytosis (HLH) in a patient of Scrub typhus is being reported here. Such association of scrub typhus and HLH is rare.

Hemophagocytic Lymphohistiocytosis in a Patient of Scrub Typhus.

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Hemophagocytic Lymphohistiocytosis in a Patient of Scrub Typhus.