Spot the dot: Solve the mystery: Tsutsugamushi disease

Scrub typhus (Tsutsugamushi disease), is an acute febrile infectious disease endemic in eastern asia is caused by Orienta Tsutsugamushi, transmitted by bite of a Leptotrombidium mite (chigger). 45 year old lady presented with progressive worsening of fever (102F), myalgias, headache and tachycardia (120/min). Leucopenia with thrombocytopenia was noted with elevated liver enzymes. Provisional diagnosis of malaria and dengue was suspected and serological tests were carried out. Paracetamol, IV fluids was given and was patient was monitored for hypotension and bleeding manifestaions. Serology for malaria and dengue were negative. Despite management fever continued to spike. Black eschar was noted on the left shoulder tip and scrub typhus was suspected because of characteristic eschar. Doxycycline was started and serology was positive for Orienta Tsutsugamushi antibodies. Patient recovered with fever and platelet counts normalizing. Recovery was uneventful. The spotting of the "black dot" i.e eschar, helped us in clinching the diagnosis that ultimately lead to the successful and uneventful recovery of this patient. A high index of clinical suspicion, prompt diagnosis and early institution of appropriate antimicrobials can decrease the morbidity and mortality.