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Scrub Typhus

(Tsutsugamushi Disease; Mite-Borne Typhus; Tropical Typhus)

By William A. Petri, Jr, MD, PhD, Wade Hampton Frost Professor of Medicine and Chief, Division of Infectious Diseases and International Health, University of Virginia School of Medicine

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Scrub typhus is a mite-borne disease caused by Orientia tsutsugamushi (formerly Rickettsia tsutsugamushi). Symptoms are fever, a primary lesion, a macular rash, and lymphadenopathy.

Scrub typhus is related to rickettsial diseases.

O. tsutsugamushi is transmitted by trombiculid mite larvae (chiggers), which feed on forest and rural rodents, including rats, voles, and field mice. Human infection also follows a chigger bite. The mites are both the vector and the natural reservoir for O. tsutsugamushi.

Scrub typhus is endemic in an area of Asia-Pacific bounded by Japan, Korea, China, India, and northern Australia.

Symptoms and Signs

After an incubation period of 6 to 21 days (mean 10 to 12 days), fever, chills, headache, and generalized lymphadenopathy start suddenly. At onset of fever, an eschar often develops at the site of the chigger bite. The typical lesion of scrub typhus, common in whites but rare in Asians, begins as a red, indurated lesion about 1 cm in diameter; it eventually vesiculates, ruptures, and becomes covered with a black scab. Regional lymph nodes enlarge.

Fever rises during the 1st wk, often to 40 to 40.5° C. Headache is severe and common, as is conjunctival injection. A macular rash develops on the trunk during the 5th to 8th day of fever, often extending to the arms and legs. It may disappear rapidly or become maculopapular and intensely colored. Cough is present during the 1st wk of fever, and pneumonitis may develop during the 2nd wk.

In severe cases, pulse rate increases; BP drops; and delirium, stupor, and muscular twitching develop. Splenomegaly may be present, and interstitial myocarditis is more common than in other rickettsial diseases. In untreated patients, high fever may persist 2 wk, then falls gradually over several days. With therapy, defervescence usually begins within 36 h. Recovery is prompt and uneventful.


  • Clinical features

  • Biopsy of rash with fluorescent antibody staining to detect organisms

  • Acute and convalescent serologic testing (serologic testing not useful acutely)

  • PCR


  • Doxycycline

Primary treatment is doxycycline 200 mg po once followed by 100 mg bid until the patient improves, has been afebrile for 48 h, and has received treatment for at least 7 days.

Chloramphenicol 500 mg po or IV qid for 7 days is 2nd-line treatment.

Clearing brush and spraying infested areas with residual insecticides eliminate or decrease mite populations. Insect repellents (eg, diethyltoluamide [DEET]) should be used when exposure is likely.

Key Points

  • Scrub typhus, endemic in Asia-Pacific, is transmitted by the bite of chiggers (mite larvae).

  • Fever (often accompanied by an eschar at the bite site), chills, severe headache, and generalized lymphadenopathy start suddenly; a rash develops and spreads.

  • Treat with doxycycline, which results in rapid improvement even in severe cases.

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