A 23-year-old previously healthy male, with no known comorbidities presented with 10 days of high-grade fever, watery diarrhea, diffuse crampy abdominal pain, vomiting, chills and rigors. He had a history of outside food intake prior to symptom onset. Initially Patient was admitted in an outside hospital and was treated with intravenous cefoperazone-sulbactam and metronidazole from day 5 of fever yet showed no improvement.
On evaluation, platelet count dropped from 76,000 to 39,000 within 24 hours, on day 5. Due to persistent symptoms ,he was brought here for further management.
The patient was conscious, oriented , febrile, Dehydrated and icteric. The patient was dyspneic and tachypneic. Bp- 150/82 mmHg, PR-136/min, SPO2 – 96 in room air, RR- 30/min. CVS- S1 S2 present, No murmurs. RS- BAE present. NVBS. No added sounds. P/A- Diffuse tenderness, guarding, rigidity more towards the epigastric , right and left hypochondrial and right iliac fossa.
At admission to our facility on day 11 of fever, labs revealed: Hb 11.5 g/dL, WBC 3760/µL with 82% neutrophils, platelets 81,000/µL, SGOT 569 U/L, SGPT 168 U/L, GGT 200 U/L, urea 54.8 mg/dL, creatinine 1.96 mg/dL, sodium 131 mEq/L, potassium 2.7 mEq/L, phosphorus 1.8 mg/dL. CRP was elevated at 133.4 mg/L, NT-proBNP 11284 pg/mL, procalcitonin 17.35 ng/mL. Serum lipase was 284.6 U/L and amylase 707.3 U/L. Troponin I was significantly elevated at 112.17 ng/L, and CPK was 1341.6 U/L. Urine microscopy revealed 8–10 isomorphic RBCs per high-power field.
CT abdomen with contrast showed ileocolitis involving the terminal ileum, appendix, and cecum with mesenteric lymphadenopathy, hepatosplenomegaly, ascites, and enlarged kidneys with perinephric fat stranding. CT chest revealed bilateral pleural effusions, basal lung consolidations, and enlarged pulmonary arteries suggestive of systemic inflammation.
ECHO done showed Mild PAH with PASP- 45, otherwise no significant abnormality.
The above findings confirm the presence of multi-system involvement
Serologic testing revealed Typhidot IgM and Scrub typhus IgM positivity. Blood cultures were sterile, likely due to prior antibiotics. A diagnosis of co-infection with typhoid fever and scrub typhus was established.
The patient was admitted and started on intravenous ceftriaxone- 2 grams IV BD and doxycycline 100mg BD over 7 days. Clinical improvement was noted within 48–72 hours. Supportive treatment included fluid and electrolyte correction, potassium repletion, and monitoring for cardiac and renal function. The patient was supportively managed by the Intensive Care Unit team , surgeon, cardiologist and nephrologist in a multidisciplinary approach.
Over the course of a week, the patient’s symptoms resolved, and laboratory parameters gradually normalized. Repeat ECHO showed resolution of PAH. He was discharged with oral antibiotics , diuretics, fluid restriction as outpatient follow-up and complete recovery.
This case illustrates the diagnostic complexity of co-infections in endemic regions. Both typhoid and scrub typhus are common causes of febrile illness, yet simultaneous infection is rare and often underrecognized. The patient’s multi-organ involvement, resistance to monotherapy, and response to combined treatment underscored the importance of broad diagnostic evaluation in persistent tropical fevers. Awareness and timely intervention are key to preventing morbidity in such overlapping infections.
Scrub typhus is a serious public health problem in the “tsutsugamushi triangle” region, which comprises the Asia-Pacific nations and the Indian subcontinent [1].The disease is prevalent in India’s Sub-Himalayan region, which extends from Jammu and Kashmir to Nagaland. It is also prevalent in West Bengal, Tamil Nadu, and Kerala. Scrub typhus is a tropical infectious disease caused by Orientia tsutsugamushi, a gram-negative, intracellular, obligatory pathogen whose polysaccharides have an antigenic association with proteus OX-K and are therefore utilised in serologic testing to diagnose scrub typhus. Most common presentations include fever, exanthematous rash, myalgia, headache, gastrointestinal problems, dyspnea, jaundice, and eschar formation. In extreme cases, multiorgan dysfunction syndrome (MODS), meningitis, encephalitis, acute respiratory distress syndrome, acute lung injury (ALI), pre-renal AKI, and myocarditis might occur. The severity of renal involvement caused by scrub typhus infection can range from asymptomatic urine abnormalities to renal failure requiring dialysis. Acute arrest of hemopoiesis (AAH) which usually results in pancytopenia, might occur with scrub infection and patients will have a considerable improvement in their blood routine for about a week after receiving supportive care.
Co-infection with Salmonella typhi and scrub typhus should be considered in patients presenting with systemic symptoms, gastrointestinal complaints, and organ dysfunction in endemic areas. Empirical treatment targeting both pathogens may be warranted when diagnostic ambiguity exists.
1) Lallawmkima I, Vanlalruati R, Chongthu JL, Renthlei L. Scrub Typhus with Multi-Organ Dysfunction Syndrome and Immune Thrombocytopenia: A Case Report. Infect Dis Clin Microbiol. 2022 Jun 13;4(2):133-136. doi: 10.36519/idcm.2022.95. PMID: 38633345; PMCID: PMC10986586.
2)A Rare Presentation of Scrub Typhus: Multi-Organ Dysfunction [Acute Kidney Injury, Hepatitis] and Acute Respiratory Distress Syndrome Published: 2023-01-05 | DOI: 10.9734/ajrid/2023/v12i1232 | Page: 1-7 | Issue: 2023 – Volume 12 [Issue 1]
3)Typhoid and Scrub Typhus Coinfection in a Returned Traveler SAGE Publications Inc | Global Pediatric Health | August 20174(2):2333794X1772694 DOI:10.1177/2333794X17726941 | LicenseCC BY-NC 4.0
4)Bhattarai BR, Bhujel R, Pokhrel S, Mishra A, Priyadarshinee A. Co-infection of dengue, scrub typhus, and typhoid during dengue outbreak in Nepal, 2022: A case report. Clin Case Rep. 2023 Mar 14;11(3):e7080. doi: 10.1002/ccr3.7080. PMID: 36937629; PMCID: PMC10014518.
Dr. K Jayaraman Senior Consultant Internal Medicine Specialist and Diabetologist, Kauvery Hospital Chennai
Dr N Roseline Sweety Jebapriya DNB General Medicine First Year Resident, Kauvery Hospital Chennai
