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Scrub Typhus Clinical Presentation

  • Author: David J Cennimo, MD, FAAP, FACP, AAHIVS; Chief Editor: Russell W Steele, MD  more...
Updated: Oct 01, 2015


Patients with scrub typhus may present early or later in the course of their disease. In the United States, a history of travel to the endemic area must be sought, specifically probing for exposures in rural areas and contact with vegetation or the ground.[3, 6, 13]

Inoculation through the chigger bite is often painless and unnoticed. The incubation period lasts 6-20 days (average, 10 days). After incubation, persons may experience headaches, shaking chills, lymphadenopathy, conjunctival infection, fever, anorexia, and general apathy. The fever usually reaches 40-40.5°C (104-105°F).

A small painless papule initially appears at the site of infection and enlarges gradually. An area of central necrosis develops and is followed by eschar formation. The eschar (if present) is well developed at the initiation of the fevers, which may drive the patient to seek medical attention.[3, 4, 11, 33, 34]

Diagnosing scrub typhus early in its course can be difficult because many conditions can present with a high fever; however, the presentation of the rash, a history of exposure to endemic areas, and the presentation of the sore caused by the bite can be diagnostic.


Physical Examination

The site of infection is marked by a chigger bite. Approximately 50% of patients with primary infection and 30% of patients with recurrent infection develop an eschar at the inoculation site (see the images below). Given the appropriate history, the eschar is often pathognomonic, but it may be missed by an inexperienced observer.

Typical eschar. Typical eschar.
Eschar on neck. Eschar on neck.
Eschar on scrotum. Eschar on scrotum.

In prospective studies, trained investigators were able to locate an eschar on 68-87% of patients.[8, 33] In adults, the eschar is often truncal, whereas children may have lesions in the perineum.[35] The incidence of an eschar on head, face or neck is estimated to be approximately 5%.[36] Multiple eschars may be present.[4] The eschar may also abrade, leaving an ulcer reminiscent of primary syphilis.

The presence or absence of eschar was thoroughly examined in a study of 176 Korean patients with scrub typhus confirmed by immunofluorescent assay.[35] In this study, 162 (92%) cases had eschar, with 128 (79.5%) on the front of the body. In men, eschars were detected within 30 cm below the umbilicus (19 patients; 35.8%), on the lower extremities (12 patients; 22.6%) and on the chest above the umbilicus (11 patients; 20.8%). In women, the most prevalent area was the chest above the umbilicus (44 patients; 40.7%).

Patients experience abrupt onset of high fever (40-40.5°C [104-105°F]), headache, malaise, and myalgia approximately 10 days after infection. At that time, the eschar (if present) is well formed. Fever is the most commonly reported complaint, occurring more than 98% of the time.[3, 11] Tender regional or generalized lymphadenopathy may provide a clue to diagnosis and is reported in 40-97% of cases. Less frequently, ocular pain, wet cough, malaise, and injected conjunctiva are present.[4, 8, 33, 11, 37]

Toward the end of the first week, approximately 35% (reported range, 15-93%) of patients develop a centrifugal macular rash on the trunk. The rash may progress to become papular (see the image below).[4, 11, 34] It may be transient and easily missed.[3] Additional symptoms at this time may include enlargement of the spleen, cough, and delirium. Pneumonitis or encephalitis may develop during the second week.

Maculopapular rash. Maculopapular rash.

Some patients may have central nervous system (CNS) involvement with tremors, nervousness, slurred speech, nuchal rigidity, or deafness during the second week of the disease. However, results from cerebrospinal fluid (CSF) analysis are either normal or indicate a low number of monocytes. Severe CNS involvement (eg, seizure or coma) is rare. If acute hearing loss is present (as may be the case in as many as one third of patients, according to some reports), it strongly points toward scrub typhus.[3, 6]

Some evidence of pulmonary involvement (eg, cough, tachypnea, or pulmonary infiltrates) is often present.[33] Respiratory compromise may progress to acute respiratory distress syndrome (ARDS), especially in the elderly.[32]

Cardiac involvement is often minor and rare; however, cases of fatal myocarditis have been reported.[38] Infection with O tsutsugamushi may cause a relative bradycardia,[39] which, when combined with rash, may raise concern for typhoid fever.[8]

Scrub typhus may rarely cause acute renal failure, shock, and disseminated intravascular coagulation (DIC).[3]

If the patient does not receive treatment, symptoms may last for more than 2 weeks; with treatment, the patient recovers within 36 hours.



Scrub typhus patients who are not treated may develop serious complications and may even die. Mortality ranges from 1% to 60%, depending on the geographic area and the pathogenic strain. Death can occur either from the primary infection or from secondary complications (eg, pneumonitis, encephalitis, or circulatory failure). Most fatalities occur by the end of the second week of infection.

Scrub typhus has an increased potential for complications when patients are older than 60 years, present without eschar, or have white blood cell (WBC) counts higher than 10,000/μL.[40] This condition represents an important cause of fever associated with poor pregnancy outcomes in refugee camps on the Thai-Burmese border.[41]  Another study reported that more than a third of pregnant women with murine typhus or scrub typhus infection have poor neonatal outcomes.[42, 43]

Contributor Information and Disclosures

David J Cennimo, MD, FAAP, FACP, AAHIVS Assistant Professor of Medicine and Pediatrics, Adult and Pediatric Infectious Diseases, Director, Disease Processes, Prevention, and Therapeutics, Director, Pediatric Infectious Diseases Fellowship, Rutgers New Jersey Medical School

David J Cennimo, MD, FAAP, FACP, AAHIVS is a member of the following medical societies: American Academy of Pediatrics, American College of Physicians, American Medical Association, Infectious Diseases Society of America, Medical Society of New Jersey, Pediatric Infectious Diseases Society, HIV Medicine Association, American Academy of HIV Medicine

Disclosure: Nothing to disclose.


Arry Dieudonne, MD Associate Professor of Pediatrics, Division of Pulmonology, Allergy, Immunology and Infectious Diseases, Rutgers New Jersey Medical School; Clinical Director, Francois-Xavier Bagnold Center for Children, University Hospital

Arry Dieudonne, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.


David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Lippincott Williams Wilkins Royalty Textbook editor; DLA Piper Consulting fee Consulting

Janet Fairley, MD Professor and Head, Department of Dermatology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Janet Fairley, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Federation for Medical Research, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Aracelis D Fernandez, MD, FAAP Attending Physician, Assistant Professor of Pediatrics, Assistant Professor of Immunology an, Department of Pediatrics, Children's Hospital at Albany Medical Center

Aracelis D Fernandez is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Cris Jagar MD, Staff Physician, Department of Psychiatry, Trinitas Regional Medical Center

Disclosure: Nothing to disclose.

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Rosemary Johann-Liang, MD Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration

Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Larry I Lutwick, MD Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

José Rafael Romero, MD Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center

José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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Transmission electron micrograph depicts peritoneal mesothelial cell of mouse that had been experimentally infected intraperitoneally with Orientia tsutsugamushi. Several organisms are visible within mesothelial cell's cytoplasm.
Eschar on neck.
Eschar on scrotum.
Typical eschar.
Maculopapular rash.
Chigger. Image taken from "Food and Environmental Hygiene Department" Web site and is reproduced under license from the Government of Hong Kong Special Administrative Region.
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