Scrub Typhus (ST) is a disease endemic to South-east Asia and Australia, now also being reported from North America. While early treatment consistently ensures swift recovery with no sequelae, unfortunately, this common cause of febrile illness is frequently underdiagnosed, even in endemic regions, due to non-specific presentation, low index of suspicion and/or lack of diagnostic facilities. We present a rare case of ST with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH).

A 28-year-old male with a week's history of altered sensorium, fever, headache, cough, diarrhea and dyspnea was brought to a hospital in northern India, diagnosed with multi-organ dysfunction syndrome and admitted in ICU. Having developed acute respiratory distress syndrome, septic shock and stage-3 acute kidney injury requiring four hemodialyses, he was intubated for a week, and provided empirical antibacterial, antiviral, and antifungal medications. MRI brain revealed ICH and SAH despite normal coagulation profile and platelet counts. Extensive work-up did not disclose the etiology, following which he was referred to the apex public hospital of the province. 

At our tertiary-care centre, we continued ICU and ventilatory support, broad-spectrum antimicrobials and mannitol, while we investigated him with a wide differential. We found him positive for anti-ST IgM antibody and started doxycycline on third day in our ICU. However, patient expired on sixth day due to progressive CO₂ retention.

Post-introduction of serological testing, many cases worldwide, previously labelled as ‘fever of unknown origin’, were reported to be of ST. Because ST can manifest with multi-organ dysfunction and/or death in cases of therapeutic delay, early diagnosis is critical. Here, ICH could have been secondary to uremic platelet dysfunction or to pre-existing aneurysms, for which CT angiography could not be conducted due to early mortality. We recommend serological testing for ST to be carried out early, as part of febrile illness work-up.