Unveiling the Unseen: Scrub Typhus with Myoclonic Status Epilepticus and MODS

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The clinical manifestations of scrub typhus are variable, and without timely treatment, the disease may progress to multiple organ dysfunction syndrome (MODS). This paper presents a case study of scrub typhus with myoclonic status epilepticus and MODS. Case presentation : A 72-year-old Asian male with a medical history of schizophrenia was hospitalized following one week of persistent, involuntary bilateral limb jerking at awaking. Physical examination revealed an eschar on the left scrotum. Targeted next-generation sequencing (tNGS) confirmed the presence of Orientia tsutsugamushi . The patient was diagnosed with scrub typhus, presenting with myoclonic status epilepticus and multiple organ dysfunction syndrome. Conlusion : In high-prevalence areas, physicians should carefully exclude scrub typhus in patients with neurological symptoms and acute febrile. illness. Timely and effective treatment is essential for curing the disease. Scrub Typhus Myoclonic Status Epilepticus multiple organ dysfunction syndrome targeted next-generation sequencing Figures Figure 1 Introduction Orientia tsutsugamushi causes scrub typhus, an acute febrile illness transmitted by the bite of infected chiggers, the larval stage of mites[ 1 ]. This disease is predominantly endemic to the Asia-Pacific region and poses a significant public health threat, impacting approximately one billion individuals globally. Annually, it accounts for one million cases, highlighting its critical importance in endemic areas. The high prevalence in densely populated regions and the potential for outbreaks necessitate continuous surveillance and the implementation of effective prevention strategies[ 2 , 3 ]. The disease is characterized by non-specific symptoms, making early diagnosis challenging. A distinctive clinical feature is the formation of an eschar at the site of the chigger bite, resembling a small black scab[ 4 ]. In severe cases, scrub typhus can lead to serious complications affecting multiple organ systems, including septic shock, acute respiratory distress syndrome, meningoencephalitis, pericarditis, pneumonitis, jaundice, acute renal failure, myocarditis, and disseminated intravascular coagulation[ 5 ]. Untreated scrub typhus has a mortality rate of up to 30%[ 6 ]. Seizures occur in 6.3–21.6% of scrub typhus cases[ 7 , 8 ]. According to the International League Against Epilepsy (ILAE), status epilepticus is defined as five minutes of sustained seizure activity for convulsive status epilepticus and ten minutes for focal or absence status epilepticus[ 9 ]. Currently, there are no reports of scrub typhus accompanied by myoclonic status epilepticus and MODS. Here, we report a case of scrub typhus with myoclonic status epilepticus and MODS, exploring the diagnostic and therapeutic approach. Case presentation The patient is a 72-year-old Asian man with a history of schizophrenia, typically managed with daily olanzapine. He discontinued the medication a week prior due to limb jerking. He denies any history of smoking or alcohol use. The patient was admitted to hospital with persistent involuntary bilateral limb jerking at awaking for one week, accompanied by fever (maximum 39°C), cough, insomnia, hallucinations, wandering, oliguria, and anorexia. A day before admission, CT scans from a local hospital revealed multiple lacunar infarcts around the bilateral lateral ventricles and basal ganglia, and infection in the lower lobes of both lungs. Symptoms persisted despite cefotazobactam sodium treatment. Upon admission, the patient's vital signs were as follows: respiratory rate of 28 bpm, temperature of 37.3℃, heart rate of 96 bpm and blood pressure of 107/66 mmHg. Examination showed red conjunctivae, slightly sluggish bilateral pupillary light reflexes, communication difficulties, uncooperativeness, neck muscle tension, and rhythmic jerking of all four extremities at 2–3 Hz, particularly in the upper limbs, with involuntary facial tremor. An eschar of 0.5 cm was found on the left scrotum (see Fig. 1 A). The test results showed an obvious acidosis, blood urea nitrogen and creatinine levels rose rapidly, indicating severe acute kidney injury. The rapid decrease in platelets indicated severe thrombocytopenia, and the severely low albumin indicated significant endothelial damage. There was a moderate effect on the liver with elevated gamma glutamyl transpeptidase, total bilirubin, alkaline phosphatase, aspartate aminotransferase and alanine aminotransferase. Elevated troponin, myoglobin and CK-MB indicate acute myocardial injury. Lactate dehydrogenase is moderately elevated, APTT is slightly prolonged, and blood calcium is slightly decreased, sodium and potassium ions were essentially near normal (see Table 1 ). Sputum and blood cultures, as well as the 1,3-β-D-glucan test, were negative. Additionally, tests for syphilis, HIV and viral hepatitis B and C were also negative. Although the Weil-Felix test was negative, the presence of an eschar led us to strongly suspect scrub typhus. Targeted next-generation sequencing (tNGS) was performed on the patient's alveolar lavage fluid to confirm this suspicion. The tNGS results revealed the presence of the pathogenic microorganism Orientia tsutsugamushi and a suspected colonization of the gram-positive bacterium Enterococcus faecium. On day 9, the patient's gastric fluid appeared reddish, and a positive occult blood test suggested stress-induced gastric mucosal lesions. Table 1 Lab investigations Hospital day Day1 Day2 Day3 Day4 Day5 Day6 Day9 WBC (3.5–9.5×10 9 /L) 9.6 10.2 10.2 16.1 18.4 25.4 17.2 N% (40%−75%) 80 74.9 82.3 68.3 71.4 72.0 67.4 PLT (125–350×10 9 /L) 106 75 43 24 34 45 64 HGB (130−175g/L) 119 112 118 110 111 110 85 hs-CRP (0–4 mg/L) 132.5 105.83 34.79 175.56 Albumin (40.0–55.0 g/L) 21.8 18.4 29.5 30.1 AST (40.0–55.0 U/L) 214 214 160 120 ALT (9–50 U/L) 141 101 63 51 Alkaline phosphatase (45–125 U/L) 219 194 104 106 Total bilirubin (0–23.0 µmol/L) 34.5 41.6 106.3 gamma glutamyl transferase (10–60 U/L) 126 161 100 94 pH (7.35–7.45) 7.25 7.32 7.35 7.41 7.46 7.37 BUN (3.6–9.5 mmol/L) 33.45 36.12 42.49 15.80 22.10 Creatinine (44.0−133.0 µmol/L) 578.3 639.6 678.2 204.3 282.0 Sodium (137.0−147.0 mmol/L) 141.3 140.6 140.9 139.3 134.9 Potassium (3.50–5.30 mmol/L) 3.60 4.30 4.34 3.85 4.41 Calcium (2.08–2.60 mmol/L) 1.95 1.88 2.52 PT (9.90–12.80 s) 10.10 12.20 11.70 12.30 11.20 10.80 11.80 APTT (25.10–36.50 s) 40.60 47.10 52.90 55.30 41.00 40.20 55.30 INR (0.88–1.08) 0.92 1.11 1.07 1.12 1.02 0.98 1.07 PCT (0−0.05 ng/mL) 9.13 5.51 3.09 hs-cTnT (0–14 pg/mL) 317.0 875.0 1211.0 Myoglobin (28–72 ng/mL) 1321.0 721.0 193.0 CK-MB (0−4.87 ng/mL) 29.80 13.80 3.78 LDH (120–250 U/L) 798 746 620 497 WBC, white blood cells; N %, neutrophil percentage; PLT, platelets; HGB, haemoglobin; hs-CRP, High-sensitivity C-reactive protein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, gamma glutamyl transpeptidase; BUN, blood urea nitrogen; PT, prothrombin time; APTT, activated partial thromboplastin time; INR, international normalised ratio; PCT, procalcitonin; hs-cTnT, high-sensitivity cardiac troponin; CK-MB, creatine kinase-MB; LDH, lactate dehydrogenase. Intravenous diazepam (10mg) temporarily halted seizures, allowing the patient to sleep for about half an hour, but the seizures resumed once the drug's effects wore off. Maintenance intravenous diazepam (2.4 mg/kg/d) also failed to control seizures. Intravenous midazolam and propofol ultimately controlled limb convulsions, and oral sodium valproate was added for antiepileptic treatment. On day 1, due to worsening hypoxaemia and oliguria, mechanical ventilation and continuous renal replacement therapy were initiated. Initial anti-infective treatment with piperacillin sodium-sulbactam sodium (4.5 g, IV q6h), and following the tNGS results, a triple anti-infective treatment was added with doxycycline (0.2g, PO q12h) in combination with omadine (0.1g, IV qd), given the patient's severe condition with septic shock and suspected scrub typhus. Supportive measures including maintenance of homeostasis, platelet transfusion, acid inhibition and liver protection were also given. Following the rescue treatment, the patient's condition gradually stabilized, with improvements in breathing and oxygenation, and gradual healing of the scabs in the left scrotum on day 7 (see Figure 1 B). However, as his family could not afford the medical costs, the treatment was discontinued and the patient died after discharge home. Discussion This study discusses a 72-year-old Asian man with prolonged limb convulsions while maintaining consciousness, and scabs visible on the left scrotum, diagnosed with scrub typhus by tNGS. The patient experienced multiple complications including status epilepticus, renal failure, septic shock, respiratory failure, thrombocytopenia, upper gastrointestinal bleeding, impaired liver function, hypoalbuminemia, and myocardial injury. Scabs are highly specific for scrub typhus (98.9%) but vary significantly in prevalence (7.0–97%)[ 10 , 11 ]. Therefore, diagnosis requires both presumptive and definitive tests, such as serological tests including Weil-Felix, ELISA, immunofluorescence assay (IFA), and rapid diagnostic tests. The Weil-Felix test is commonly used in developing countries due to its simplicity, quick results, and low cost, despite poor specificity and sensitivity[ 12 , 13 ]. Metagenomic NGS (mNGS) sequences extensive DNA/RNA from a sample to detect unexpected pathogens, while tNGS enriches specific genetic targets, including particular pathogens[ 14 , 15 ]. To date, few scrub typhus cases have been confirmed by tNGS from bronchoalveolar lavage fluid. Neurological involvement in scrub typhus is about 20%, with rare neurological manifestations being even less common[ 16 ]. Meningitis and meningoencephalitis are the most common neurological manifestations, rare and difficult to diagnose conditions such as post-infectious seizures (including status epilepticus), transverse myelitis, acute disseminated encephalomyelitis, cerebral infarction, cerebral venous thrombosis, subarachnoid hemorrhage, encephalitis, encephalomyelopathy, Guillain-Barré syndrome, Parkinson's syndrome, and psychiatric symptoms are less well described but well established clinical entities[ 17 – 20 ]. The patient exhibited bilateral myoclonic jerks at awakening for 7 days on admission, considered myoclonic status epilepticus without coma. Myoclonic status epilepticus generally involves prolonged or frequent myoclonic seizures, status epilepticus are typically associated with comatose states in other conditions, making this presentation unusual. The occurrence of status epilepticus as a complication of scrub typhus is notably rare in medical literature. While scrub typhus is known for various systemic impacts, its direct association with such severe neurological involvement, especially in the form of myoclonic status epilepticus without coma, is not commonly documented[ 8 , 21 ]. The precise cause of the patient's status epilepticus is unknown, as a lumbar puncture was declined by the family. We suspect scrub typhus meningitis or meningoencephalitis to be the most likely cause, as central nervous system infections are the predominant cause of status epilepticus in scrub typhus based on clinical presentation and similar cases reported in the literature[ 8 , 22 ]. The CNS manifestations of scrub typhus often result from small-vessel vasculitis, leading to a breakdown of the blood-brain barrier and resulting in cerebral edema and microinfarctions[ 23 ]. The organism has been observed in cerebrospinal fluid previously[ 24 ]. Patients with status epilepticus in scrub typhus may have better outcomes compared to other CNS infections due to favorable treatment response. Doxycycline, tetracycline, azithromycin and chloramphenicol are the most common antibiotics for the treatment of scrub typhus[ 25 ]. Unfortunately, despite receiving accurate treatment and showing gradual improvement, the patient's family discontinued treatment due to financial constraints, leading to the patient's deterioration and subsequent death. Conclusion Especially when patients present with acute fever accompanied by neurological symptoms, physicians must maintain high suspicions of scrub typhus in areas where the disease is prevalent. We report a case of scrub typhus with myoclonic status epilepticus without coma and MODS. Managing scrub typhus with MODS requires a comprehensive treatment approach. Anti-epileptic, anti-rickettsial therapy as well as advanced life support. Abbreviations MODS, multiple organ dysfunction syndrome; tNGS, Targeted next-generation sequencing; mNGS, Metagenomic next-generation sequencing; ILAE, International League Against Epilepsy; WBC, white blood cells; N %, neutrophil percentage; PLT, platelets; HGB, haemoglobin; hs-CRP, High-sensitivity C-reactive protein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, gamma glutamyl transpeptidase; BUN, blood urea nitrogen; PT, prothrombin time; APTT, activated partial thromboplastin time; INR, international normalised ratio; PCT, procalcitonin; hs-cTnT, high-sensitivity cardiac troponin; CK-MB, creatine kinase-MB; LDH, lactate dehydrogenase. Declarations Acknowledgments The authors wish to thank the patient for participating in this study and all the staf members at our institution. Authors’ contributions LFE, GXJ, CXB and XTX was involved in patient treatment. GXJ and LFE were responsible for the study design and literature search. WLG, CXB and XTX were mainly responsible for the data interpretation and critical revision. GXJ wrote manuscript drafting. LFE are corresponding authors. GXJ are first authors. All authors read and approved the final manuscript. Funding No funding. Availability of data and materials All data generated or analyzed during this study are included in this published article. Ethics approval and consent to participate The study protocol was approved by the Institutional Review Board of Second Affiliated Hospital of Shantou University Medical College. Consent for publication Written informed consent was obtained from the patient's family for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Competing interests None of the authors have conflicts of interest to disclose or a financial relationship with a commercial entity that has interest in the subject of the manuscript. 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Kalita J, Mani VE, Bhoi SK, Misra UK. Status epilepticus in scrub typhus. Epilepsia. 2016;57. Trinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S, et al. A definition and classification of status epilepticus – report of the ILAE task force on classification of status epilepticus. Epilepsia. 2015;56:1515–23. Paris DH, Shelite TR, Day NP, Walker DH. Unresolved problems related to scrub typhus: A seriously neglected life-threatening disease. Am Soc Trop Med Hygiene. 2013;89:301–7. Saraswati K, Day NPJ, Mukaka M, Blacksell SD. Scrub typhus point-of-care testing: A systematic review and meta-analysis. Plos Negltrop Dis. 2018;12:e0006330. Kim DM, Lee Y-M, Back J-H, Yang TY, Lee JH, Song H-J, et al. A serosurvey of orientia tsutsugamushi from patients with scrub typhus. Clin Microbiol Infec. 2010;16:447–51. Kala D, Gupta S, Nagraik R, Verma V, Thakur A, Kaushal A. Diagnosis of scrub typhus: Recent advancements and challenges. 3 Biotech. 2020;10:396. Chiu CY, Miller SA. Clinical metagenomics. Nat Rev Genet. 2019;20:341–55. Gaston DC, Miller HB, Fissel JA, Jacobs E, Gough E, Wu J, et al. Evaluation of metagenomic and targeted next-generation sequencing workflows for detection of respiratory pathogens from bronchoalveolar lavage fluid specimens. J Clin Microbiol. 2022;60:e00526–22. Ghosh R, Mandal A, León-Ruiz M, Roy D, Das S, Dubey S et al. Rare neurological and neuropsychiatric manifestations of scrub typhus: a case series of 10 cases. Neurología (English Edition). 2022;:S2173580822000815. Basu S, Chakravarty A. Neurological manifestations of scrub typhus. Curr Neurol Neurosci Rep. 2022;22:491–8. Misra UK, Kalita J, Mani VE. Neurological manifestations of scrub typhus. J Neurol Neurosurg Psychiatry. 2015;86:761–6. Rana A, Mahajan SK, Sharma A, Sharma S, Verma BS, Sharma A. Neurological manifestations of scrub typhus in adults. Trop Doct. 2017;47:22–5. Mahajan SK, Mahajan SK. Neuropsychiatric manifestations of scrub typhus. J Neurosciences Rural Pract. 2017;08:421–6. Alam AM, Gillespie CS, Goodall J, Damodar T, Turtle L, Vasanthapuram R, et al. Neurological manifestations of scrub typhus infection: A systematic review and metaanalysis of clinical features and case fatality. Plos Negltrop Dis. 2022;16:e0010952. Trinka E, Höfler J, Zerbs A. Causes of status epilepticus. Epilepsia. 2012;53:127–38. Dittrich S, Sunyakumthorn P, Rattanavong S, Phetsouvanh R, Panyanivong P, Sengduangphachanh A, et al. Blood-brain barrier function and biomarkers of central nervous system injury in rickettsial versus other neurological infections in laos. Am J Trop Med Hyg. 2015;93:232–7. Drevets DA, Leenen PJM, Greenfield RA. Invasion of the central nervous system by intracellular bacteria. Clin Microbiol Rev. 2004;17:323–47. Wee I, Lo A, Rodrigo C. Drug treatment of scrub typhus: A systematic review and meta-analysis of controlled clinical trials. Trans R Soc Trop Med Hyg. 2017;111:336–44. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Nov, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 13 Jan, 2025 Reviews received at journal 04 Dec, 2024 Reviews received at journal 01 Dec, 2024 Reviewers agreed at journal 27 Nov, 2024 Reviewers agreed at journal 27 Nov, 2024 Reviewers invited by journal 27 Nov, 2024 Editor invited by journal 29 Oct, 2024 Editor assigned by journal 28 Oct, 2024 Submission checks completed at journal 28 Oct, 2024 First submitted to journal 24 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5326356","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":372711380,"identity":"5e26f748-3b3c-49c1-869d-b01975d926ad","order_by":0,"name":"Xiaojin Gan","email":"","orcid":"","institution":"Second Affiliated Hospital of Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xiaojin","middleName":"","lastName":"Gan","suffix":""},{"id":372711381,"identity":"4e8e4ecf-2194-410c-abf7-695f9bb6e2d2","order_by":1,"name":"Xianbin Cai","email":"","orcid":"","institution":"Second Affiliated Hospital of Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xianbin","middleName":"","lastName":"Cai","suffix":""},{"id":372711382,"identity":"2f1e5985-6cd7-40a3-a4e3-65b4e6022806","order_by":2,"name":"Tangxin Xin","email":"","orcid":"","institution":"Second Affiliated Hospital of Shantou University Medical College","correspondingAuthor":false,"prefix":"","firstName":"Tangxin","middleName":"","lastName":"Xin","suffix":""},{"id":372711383,"identity":"da43745e-4af3-4cab-9250-78ff8c6de26a","order_by":3,"name":"Feng-E Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYBACNmb+hw8+/pGQY2NvPkCcFj72HmbDmQ02xvw8xxKI0yLHc4ZNmrchLVFyRo4BkQ6TyD0mwbvjcILBjZyPN94w2MnpNhDUkpdsIXnmcJ7BmbebLecwJBubHSCoJcHwhgHb4WKD47nbpHkYDiRuI0KLgUQC2+HEDQdynhGpheeMkcTBtrTEmR05bERqYW9LNmw4Aw5kY8s5BkT4Rb6Z+eDjPxXgqHx4402FnRxBLShAgofIqEHWQqqOUTAKRsEoGBEAAKvTRHMLK3TJAAAAAElFTkSuQmCC","orcid":"","institution":"Second Affiliated Hospital of Shantou University Medical College","correspondingAuthor":true,"prefix":"","firstName":"Feng-E","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-10-24 13:38:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5326356/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5326356/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-11702-y","type":"published","date":"2025-11-21T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69249378,"identity":"a883329c-5df5-4a9c-ae9c-a7518f132129","added_by":"auto","created_at":"2024-11-18 11:30:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8721284,"visible":true,"origin":"","legend":"\u003cp\u003eThe eschar on the scrotum before treatment (A) and after treatment (B).\u003c/p\u003e","description":"","filename":"fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-5326356/v1/e8c13048c6919d60f35994db.png"},{"id":96650325,"identity":"dbdaeb56-3f25-40ea-a7c4-2882e03a46d7","added_by":"auto","created_at":"2025-11-24 16:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8890806,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5326356/v1/757e8c5d-d9ef-4408-b27b-83def91775f8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Unveiling the Unseen: Scrub Typhus with Myoclonic Status Epilepticus and MODS","fulltext":[{"header":"Introduction","content":"\u003cp\u003e \u003cem\u003eOrientia tsutsugamushi\u003c/em\u003e causes scrub typhus, an acute febrile illness transmitted by the bite of infected chiggers, the larval stage of mites[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This disease is predominantly endemic to the Asia-Pacific region and poses a significant public health threat, impacting approximately one billion individuals globally. Annually, it accounts for one million cases, highlighting its critical importance in endemic areas. The high prevalence in densely populated regions and the potential for outbreaks necessitate continuous surveillance and the implementation of effective prevention strategies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The disease is characterized by non-specific symptoms, making early diagnosis challenging. A distinctive clinical feature is the formation of an eschar at the site of the chigger bite, resembling a small black scab[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In severe cases, scrub typhus can lead to serious complications affecting multiple organ systems, including septic shock, acute respiratory distress syndrome, meningoencephalitis, pericarditis, pneumonitis, jaundice, acute renal failure, myocarditis, and disseminated intravascular coagulation[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Untreated scrub typhus has a mortality rate of up to 30%[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeizures occur in 6.3\u0026ndash;21.6% of scrub typhus cases[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. According to the International League Against Epilepsy (ILAE), status epilepticus is defined as five minutes of sustained seizure activity for convulsive status epilepticus and ten minutes for focal or absence status epilepticus[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Currently, there are no reports of scrub typhus accompanied by myoclonic status epilepticus and MODS. Here, we report a case of scrub typhus with myoclonic status epilepticus and MODS, exploring the diagnostic and therapeutic approach.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient is a 72-year-old Asian man with a history of schizophrenia, typically managed with daily olanzapine. He discontinued the medication a week prior due to limb jerking. He denies any history of smoking or alcohol use. The patient was admitted to hospital with persistent involuntary bilateral limb jerking at awaking for one week, accompanied by fever (maximum 39\u0026deg;C), cough, insomnia, hallucinations, wandering, oliguria, and anorexia. A day before admission, CT scans from a local hospital revealed multiple lacunar infarcts around the bilateral lateral ventricles and basal ganglia, and infection in the lower lobes of both lungs. Symptoms persisted despite cefotazobactam sodium treatment.\u003c/p\u003e \u003cp\u003eUpon admission, the patient's vital signs were as follows: respiratory rate of 28 bpm, temperature of 37.3℃, heart rate of 96 bpm and blood pressure of 107/66 mmHg. Examination showed red conjunctivae, slightly sluggish bilateral pupillary light reflexes, communication difficulties, uncooperativeness, neck muscle tension, and rhythmic jerking of all four extremities at 2\u0026ndash;3 Hz, particularly in the upper limbs, with involuntary facial tremor. An eschar of 0.5 cm was found on the left scrotum (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003eThe test results showed an obvious acidosis, blood urea nitrogen and creatinine levels rose rapidly, indicating severe acute kidney injury. The rapid decrease in platelets indicated severe thrombocytopenia, and the severely low albumin indicated significant endothelial damage. There was a moderate effect on the liver with elevated gamma glutamyl transpeptidase, total bilirubin, alkaline phosphatase, aspartate aminotransferase and alanine aminotransferase. Elevated troponin, myoglobin and CK-MB indicate acute myocardial injury. Lactate dehydrogenase is moderately elevated, APTT is slightly prolonged, and blood calcium is slightly decreased, sodium and potassium ions were essentially near normal (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Sputum and blood cultures, as well as the 1,3-β-D-glucan test, were negative. Additionally, tests for syphilis, HIV and viral hepatitis B and C were also negative. Although the Weil-Felix test was negative, the presence of an eschar led us to strongly suspect scrub typhus. Targeted next-generation sequencing (tNGS) was performed on the patient's alveolar lavage fluid to confirm this suspicion. The tNGS results revealed the presence of the pathogenic microorganism Orientia tsutsugamushi and a suspected colonization of the gram-positive bacterium Enterococcus faecium. On day 9, the patient's gastric fluid appeared reddish, and a positive occult blood test suggested stress-induced gastric mucosal lesions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLab investigations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital day\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDay1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDay2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDay3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDay4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDay5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDay6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDay9\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC\u003c/p\u003e \u003cp\u003e(3.5\u0026ndash;9.5\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN%\u003c/p\u003e \u003cp\u003e(40%\u0026minus;75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e72.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e67.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT\u003c/p\u003e \u003cp\u003e(125\u0026ndash;350\u0026times;10\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGB\u003c/p\u003e \u003cp\u003e(130\u0026minus;175g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehs-CRP\u003c/p\u003e \u003cp\u003e(0\u0026ndash;4 mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e175.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin\u003c/p\u003e \u003cp\u003e(40.0\u0026ndash;55.0 g/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST\u003c/p\u003e \u003cp\u003e(40.0\u0026ndash;55.0 U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT\u003c/p\u003e \u003cp\u003e(9\u0026ndash;50 U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlkaline phosphatase (45\u0026ndash;125 U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin\u003c/p\u003e \u003cp\u003e(0\u0026ndash;23.0 \u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e106.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egamma glutamyl transferase (10\u0026ndash;60 U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epH\u003c/p\u003e \u003cp\u003e(7.35\u0026ndash;7.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBUN\u003c/p\u003e \u003cp\u003e(3.6\u0026ndash;9.5 mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e22.10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine\u003c/p\u003e \u003cp\u003e(44.0\u0026minus;133.0 \u0026micro;mol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e578.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e639.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e678.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e204.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e282.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium (137.0\u0026minus;147.0 mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e139.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e134.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium\u003c/p\u003e \u003cp\u003e(3.50\u0026ndash;5.30 mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCalcium\u003c/p\u003e \u003cp\u003e(2.08\u0026ndash;2.60 mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePT\u003c/p\u003e \u003cp\u003e(9.90\u0026ndash;12.80 s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAPTT\u003c/p\u003e \u003cp\u003e(25.10\u0026ndash;36.50 s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003cp\u003e(0.88\u0026ndash;1.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePCT\u003c/p\u003e \u003cp\u003e(0\u0026minus;0.05 ng/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehs-cTnT\u003c/p\u003e \u003cp\u003e(0\u0026ndash;14 pg/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e317.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e875.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1211.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMyoglobin (28\u0026ndash;72 ng/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1321.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e721.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e193.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCK-MB\u003c/p\u003e \u003cp\u003e(0\u0026minus;4.87 ng/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDH\u003c/p\u003e \u003cp\u003e(120\u0026ndash;250 U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e746\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e620\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eWBC, white blood cells; N %, neutrophil percentage; PLT, platelets; HGB, haemoglobin; hs-CRP, High-sensitivity C-reactive protein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, gamma glutamyl transpeptidase; BUN, blood urea nitrogen; PT, prothrombin time; APTT, activated partial thromboplastin time; INR, international normalised ratio; PCT, procalcitonin; hs-cTnT, high-sensitivity cardiac troponin; CK-MB, creatine kinase-MB; LDH, lactate dehydrogenase.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntravenous diazepam (10mg) temporarily halted seizures, allowing the patient to sleep for about half an hour, but the seizures resumed once the drug's effects wore off. Maintenance intravenous diazepam (2.4 mg/kg/d) also failed to control seizures. Intravenous midazolam and propofol ultimately controlled limb convulsions, and oral sodium valproate was added for antiepileptic treatment. On day 1, due to worsening hypoxaemia and oliguria, mechanical ventilation and continuous renal replacement therapy were initiated. Initial anti-infective treatment with piperacillin sodium-sulbactam sodium (4.5 g, IV q6h), and following the tNGS results, a triple anti-infective treatment was added with doxycycline (0.2g, PO q12h) in combination with omadine (0.1g, IV qd), given the patient's severe condition with septic shock and suspected scrub typhus. Supportive measures including maintenance of homeostasis, platelet transfusion, acid inhibition and liver protection were also given. Following the rescue treatment, the patient's condition gradually stabilized, with improvements in breathing and oxygenation, and gradual healing of the scabs in the left scrotum on day 7 (see Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). However, as his family could not afford the medical costs, the treatment was discontinued and the patient died after discharge home.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study discusses a 72-year-old Asian man with prolonged limb convulsions while maintaining consciousness, and scabs visible on the left scrotum, diagnosed with scrub typhus by tNGS. The patient experienced multiple complications including status epilepticus, renal failure, septic shock, respiratory failure, thrombocytopenia, upper gastrointestinal bleeding, impaired liver function, hypoalbuminemia, and myocardial injury.\u003c/p\u003e \u003cp\u003eScabs are highly specific for scrub typhus (98.9%) but vary significantly in prevalence (7.0\u0026ndash;97%)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, diagnosis requires both presumptive and definitive tests, such as serological tests including Weil-Felix, ELISA, immunofluorescence assay (IFA), and rapid diagnostic tests. The Weil-Felix test is commonly used in developing countries due to its simplicity, quick results, and low cost, despite poor specificity and sensitivity[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Metagenomic NGS (mNGS) sequences extensive DNA/RNA from a sample to detect unexpected pathogens, while tNGS enriches specific genetic targets, including particular pathogens[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. To date, few scrub typhus cases have been confirmed by tNGS from bronchoalveolar lavage fluid.\u003c/p\u003e \u003cp\u003eNeurological involvement in scrub typhus is about 20%, with rare neurological manifestations being even less common[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Meningitis and meningoencephalitis are the most common neurological manifestations, rare and difficult to diagnose conditions such as post-infectious seizures (including status epilepticus), transverse myelitis, acute disseminated encephalomyelitis, cerebral infarction, cerebral venous thrombosis, subarachnoid hemorrhage, encephalitis, encephalomyelopathy, Guillain-Barr\u0026eacute; syndrome, Parkinson's syndrome, and psychiatric symptoms are less well described but well established clinical entities[\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe patient exhibited bilateral myoclonic jerks at awakening for 7 days on admission, considered myoclonic status epilepticus without coma. Myoclonic status epilepticus generally involves prolonged or frequent myoclonic seizures, status epilepticus are typically associated with comatose states in other conditions, making this presentation unusual. The occurrence of status epilepticus as a complication of scrub typhus is notably rare in medical literature. While scrub typhus is known for various systemic impacts, its direct association with such severe neurological involvement, especially in the form of myoclonic status epilepticus without coma, is not commonly documented[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The precise cause of the patient's status epilepticus is unknown, as a lumbar puncture was declined by the family. We suspect scrub typhus meningitis or meningoencephalitis to be the most likely cause, as central nervous system infections are the predominant cause of status epilepticus in scrub typhus based on clinical presentation and similar cases reported in the literature[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The CNS manifestations of scrub typhus often result from small-vessel vasculitis, leading to a breakdown of the blood-brain barrier and resulting in cerebral edema and microinfarctions[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The organism has been observed in cerebrospinal fluid previously[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Patients with status epilepticus in scrub typhus may have better outcomes compared to other CNS infections due to favorable treatment response. Doxycycline, tetracycline, azithromycin and chloramphenicol are the most common antibiotics for the treatment of scrub typhus[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Unfortunately, despite receiving accurate treatment and showing gradual improvement, the patient's family discontinued treatment due to financial constraints, leading to the patient's deterioration and subsequent death.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEspecially when patients present with acute fever accompanied by neurological symptoms, physicians must maintain high suspicions of scrub typhus in areas where the disease is prevalent. We report a case of scrub typhus with myoclonic status epilepticus without coma and MODS. Managing scrub typhus with MODS requires a comprehensive treatment approach. Anti-epileptic, anti-rickettsial therapy as well as advanced life support.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMODS, multiple organ dysfunction syndrome; tNGS, Targeted next-generation sequencing; mNGS, Metagenomic next-generation sequencing; ILAE, International League Against Epilepsy;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWBC, white blood cells; N %, neutrophil percentage; PLT, platelets; HGB, haemoglobin; hs-CRP, High-sensitivity C-reactive protein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; GGT, gamma glutamyl transpeptidase; BUN, blood urea nitrogen; PT, prothrombin time; APTT, activated partial thromboplastin time; INR, international normalised ratio; PCT, procalcitonin; hs-cTnT, high-sensitivity cardiac troponin; CK-MB, creatine kinase-MB; LDH, lactate dehydrogenase.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the patient for participating in this study and all the staf members at our institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLFE, GXJ,\u0026nbsp;CXB and XTX\u0026nbsp;was involved in patient treatment. GXJ and LFE were responsible for the study design and literature search. WLG, CXB and XTX were mainly responsible for the data interpretation and critical revision. GXJ wrote manuscript drafting. LFE are corresponding authors. GXJ are first authors. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Review Board of Second Affiliated Hospital of Shantou University Medical College.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026apos;s family for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors have conflicts of interest to disclose or a financial relationship with a commercial entity that has interest in the subject of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJanardhanan J, Trowbridge P, Varghese GM. Diagnosis of scrub typhus. Expert Rev Anti-infective Therapy. 2014;12:1533\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu G, Walker DH, Jupiter D, Melby PC, Arcari CM. A review of the global epidemiology of scrub typhus. Plos Negltrop Dis. 2017;11:e0006062.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonell A, Lubell Y, Newton PN, Crump JA, Paris DH. Estimating the burden of scrub typhus: A systematic review. Plos Negltrop Dis. 2017;11:e0005838.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaraswati K, Day NPJ, Mukaka M, Blacksell SD. Scrub typhus point-of-care testing: A systematic review and meta-analysis. Plos Negltrop Dis. 2018;12:e0006330.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajapakse S, Weeratunga P, Sivayoganathan S, Fernando SD. Clinical manifestations of scrub typhus. Trans R Soc Trop Med Hyg. 2017;111:43\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRajapakse S, Rodrigo C, Fernando D. Scrub typhus: Pathophysiology, clinical manifestations and prognosis. Asian Pac J Trop Med. 2012;5:261\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisra UK, Kalita J, Mani VE. Neurological manifestations of scrub typhus. J Neurol Neurosurg Psychiatry. 2015;86:761\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalita J, Mani VE, Bhoi SK, Misra UK. Status epilepticus in scrub typhus. Epilepsia. 2016;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S, et al. A definition and classification of status epilepticus \u0026ndash; report of the \u0026lt;\u0026thinsp;span style=font-variant:Small-caps;\u0026gt;ILAE\u0026thinsp;task force on classification of status epilepticus. Epilepsia. 2015;56:1515\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParis DH, Shelite TR, Day NP, Walker DH. Unresolved problems related to scrub typhus: A seriously neglected life-threatening disease. Am Soc Trop Med Hygiene. 2013;89:301\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaraswati K, Day NPJ, Mukaka M, Blacksell SD. Scrub typhus point-of-care testing: A systematic review and meta-analysis. Plos Negltrop Dis. 2018;12:e0006330.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DM, Lee Y-M, Back J-H, Yang TY, Lee JH, Song H-J, et al. A serosurvey of orientia tsutsugamushi from patients with scrub typhus. Clin Microbiol Infec. 2010;16:447\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKala D, Gupta S, Nagraik R, Verma V, Thakur A, Kaushal A. Diagnosis of scrub typhus: Recent advancements and challenges. 3 Biotech. 2020;10:396.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiu CY, Miller SA. Clinical metagenomics. Nat Rev Genet. 2019;20:341\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGaston DC, Miller HB, Fissel JA, Jacobs E, Gough E, Wu J, et al. Evaluation of metagenomic and targeted next-generation sequencing workflows for detection of respiratory pathogens from bronchoalveolar lavage fluid specimens. J Clin Microbiol. 2022;60:e00526\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhosh R, Mandal A, Le\u0026oacute;n-Ruiz M, Roy D, Das S, Dubey S et al. Rare neurological and neuropsychiatric manifestations of scrub typhus: a case series of 10 cases. Neurolog\u0026iacute;a (English Edition). 2022;:S2173580822000815.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBasu S, Chakravarty A. Neurological manifestations of scrub typhus. Curr Neurol Neurosci Rep. 2022;22:491\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMisra UK, Kalita J, Mani VE. Neurological manifestations of scrub typhus. J Neurol Neurosurg Psychiatry. 2015;86:761\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRana A, Mahajan SK, Sharma A, Sharma S, Verma BS, Sharma A. Neurological manifestations of scrub typhus in adults. Trop Doct. 2017;47:22\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahajan SK, Mahajan SK. Neuropsychiatric manifestations of scrub typhus. J Neurosciences Rural Pract. 2017;08:421\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlam AM, Gillespie CS, Goodall J, Damodar T, Turtle L, Vasanthapuram R, et al. Neurological manifestations of scrub typhus infection: A systematic review and metaanalysis of clinical features and case fatality. Plos Negltrop Dis. 2022;16:e0010952.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrinka E, H\u0026ouml;fler J, Zerbs A. Causes of status epilepticus. Epilepsia. 2012;53:127\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDittrich S, Sunyakumthorn P, Rattanavong S, Phetsouvanh R, Panyanivong P, Sengduangphachanh A, et al. Blood-brain barrier function and biomarkers of central nervous system injury in rickettsial versus other neurological infections in laos. Am J Trop Med Hyg. 2015;93:232\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrevets DA, Leenen PJM, Greenfield RA. Invasion of the central nervous system by intracellular bacteria. Clin Microbiol Rev. 2004;17:323\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWee I, Lo A, Rodrigo C. Drug treatment of scrub typhus: A systematic review and meta-analysis of controlled clinical trials. Trans R Soc Trop Med Hyg. 2017;111:336\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Scrub Typhus, Myoclonic Status Epilepticus, multiple organ dysfunction syndrome, targeted next-generation sequencing","lastPublishedDoi":"10.21203/rs.3.rs-5326356/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5326356/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: \u003cem\u003eOrientia tsutsugamushi\u003c/em\u003e, the causative agent of scrub typhus, poses a major public health threat in the Asia-Pacific region. The clinical manifestations of scrub typhus are variable, and without timely treatment, the disease may progress to multiple organ dysfunction syndrome (MODS). This paper presents a case study of scrub typhus with myoclonic status epilepticus and MODS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e: A 72-year-old Asian male with a medical history of schizophrenia was hospitalized following one week of persistent, involuntary bilateral limb jerking at awaking. Physical examination revealed an eschar on the left scrotum. Targeted next-generation sequencing (tNGS) confirmed the presence of \u003cem\u003eOrientia tsutsugamushi\u003c/em\u003e. The patient was diagnosed with scrub typhus, presenting with myoclonic status epilepticus and multiple organ dysfunction syndrome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConlusion\u003c/strong\u003e: In high-prevalence areas, physicians should carefully exclude scrub typhus in patients with neurological symptoms and acute febrile. illness. Timely and effective treatment is essential for curing the disease.\u003c/p\u003e","manuscriptTitle":"Unveiling the Unseen: Scrub Typhus with Myoclonic Status Epilepticus and MODS","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-18 11:30:27","doi":"10.21203/rs.3.rs-5326356/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-13T19:39:12+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-04T06:45:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-01T11:12:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167143628472410198474600451064399767127","date":"2024-11-28T03:00:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337409799717560854465008180514517014322","date":"2024-11-27T08:17:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-27T08:10:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-29T08:40:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-28T23:53:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-28T23:52:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-10-24T13:36:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"529e8144-4b49-481a-920e-db91fab231a8","owner":[],"postedDate":"November 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:05:49+00:00","versionOfRecord":{"articleIdentity":"rs-5326356","link":"https://doi.org/10.1186/s12879-025-11702-y","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-11-21 15:57:46","publishedOnDateReadable":"November 21st, 2025"},"versionCreatedAt":"2024-11-18 11:30:27","video":"","vorDoi":"10.1186/s12879-025-11702-y","vorDoiUrl":"https://doi.org/10.1186/s12879-025-11702-y","workflowStages":[]},"version":"v1","identity":"rs-5326356","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5326356","identity":"rs-5326356","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}