Hemophagocytic lymphohistiocytosis-a rare life threatening association with scrub typhus: case report


  • Arashdeep Virk Department of Paediatrics, Ananta Institute of Medical Sciences, Rajsamand, Rajasthan, India
  • Mohit Singla Department of Paediatrics, Ananta Institute of Medical Sciences, Rajsamand, Rajasthan, India
  • Pranay Trivedi Department of Paediatrics, Ananta Institute of Medical Sciences, Rajsamand, Rajasthan, India
  • Prasun Bhattacharjee Department of Paediatrics, Ananta Institute of Medical Sciences, Rajsamand, Rajasthan, India
  • Abhinav Tiwari Department of Paediatrics, AIIMS, Raipur, Chhattisgarh, India




Scrub typhus, HLH, MODS, Steroids


Scrub typhus is an important cause of acute febrile illness and one of the re-emerging infectious diseases in India particularly in southern Rajasthan. Hemophagocytic lympho-histiocytosis (HLH) results from an uncontrolled and ineffective hyperinflammatory response to a variety of triggers. HLH is further subdivided into primary and secondary type. We present a case of Scrub typhus which presented with multiple organ dysfunction syndrome (MODS) and secondary HLH which is a rare entity. A 9-month-old male child presented with high grade fever with encephalopathy. Examination showed hepatosplenomegaly, cervical Lymph adenopathy with eschar mark visible on abdomen. Scrub typhus was suspected on clinical grounds and further investigations were done. Serological diagnosis was strongly positive for scrub typhus. Initially, child did not respond to doxycycline, so further investigations were done to rule out HLH which fits into criteria of secondary HLH as per the revised HLH 2004 protocol. In view of secondary HLH and MODS methylprednisolone was added to treatment. Child responded to steroids and there was complete recovery. Scrub typhus patient with progressive MODS, in spite of appropriate antimicrobial therapy should raise the suspicion of secondary HLH which is rare but life-threatening condition and steroids plays an important role in the management of this condition.


El Sayed I, Liu Q, Wee I, Hine P. Antibiotics for treating scrub typhus. Cochrane Database Systematic Rev. 2018;9(9):CD002150.

Xu G, Walker DH, Jupiter D, Melby PC, Arcari CM. A review of the global epidemiology of Scrub typhus. PLoS Neglected Trop Dis. 2017;11(11):e0006062.

Traub R, Wisseman Jr CL. The ecology of Chigger-borne rickettsiosis (Scrub typhus). J Med Entomol. 1974;11(3):237-303.

Lu D, Wang T, Luo Z, Ye F, Qian J, Zhang J, et al. Evaluation of the Therapeutic Effect of Antibiotics on Scrub Typhus: A Systematic Review and Network Meta-Analysis. Frontiers Publ Heal. 2022;10:883945.

Elliott I, Pearson I, Dahal P, Thomas NV, Roberts T, Newton PN. Scrub typhus ecology: a systematic review of Orientia in vectors and hosts. Parasites Vectors. 2019;12(1):1-36.

Kumar V, Kumar V, Yadav AK, Iyengar S, Bhalla A, Sharma N, et al. Scrub typhus is an under-recognized cause of acute febrile illness with acute kidney injury in India. PLoS Neglected Trop Dise. 2014;8(1):e2605.

Devasagayam E, Dayanand D, Kundu D, Kamath MS, Kirubakaran R, Varghese GM. The burden of Scrub typhus in India: A systematic review. PLoS Neglected Trop Dise. 2021;15(7):e0009619.

Basu A, Chowdhoury SR, Sarkar M, Khemka A, Mondal R, Datta K, et al. Scrub typhus-associated hemophagocytic lymphohistiocytosis: Not a rare entity in pediatric age group. J Trop Pediatr. 2021;67(1):fmab001.

Suganthan N, Mahakumara M, Sooriyakumar T. Hemophagocytic lymphohistiocytosis: an unusual presentation of Scrub typhus. Cureus. 2020;12(7).

Jin YM, Liang DS, Huang AR, Zhou AH. Clinical characteristics and effective treatments of scrub typhus-associated hemo-phagocytic lympho-histiocytosis in children. J Adv Res. 2019;15:111-6.






Case Reports