Scrub typhus with secondary haemophagocytic lymphohistiocytosis

A male agricultural worker, aged 50 years was admitted with fever of 60 days. He had generalized weakness and headache. He was febrile. Anaemia (haemoglobin 11.7g/dL) and thrombocytopenia (platelet count 80,000/mm3) were evident. He also developed hepatocellular hepatopathy. Other salient laboratory abnormalities included low serum fibrinogen (55 mg/dL), elevated serum creatinine (5.1 mg/dL) suggestive of disseminated intravascular coagulation (DIC). Serum procalcitonin was elevated (15.6 ng/mL). Ultrasonography abdomen showed mild hepatosplenomegaly. Weil-Felix test for scrub typhus was positive in 1:640 dilutions. Serological testing to detect scrub typhus immunoglobulin M antibodies tested positive. During the hospital course of 10 days, he developed pancytopenia (haemoglobin 8.4g/dL, total leucocyte count 3,400/mm3 and platelet count 50,000/mm3), fulminant hepatic failure, acute kidney injury, acute respiratory distress syndrome and DIC. Bone marrow study revealed haemophagocytosis. Patient was managed with intravenous antibodies and supportive management. But the patient died on the 10th day of hospitalization. The patient was diagnosed to have (IgM) scrub typhus with secondary haemophagocytic lymphohistiocytosis complicated by DIC and multiple organ dysfunction syndrome.