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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 2  |  Issue : 2  |  Page : 195-196
Eschar- A forgotten focus of concern


Department of Accident, Emergency & Critical Care Medicine, Sri Gokulam Hospital & Research Institute, Salem, Tamil Nadu, India

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Date of Web Publication30-Apr-2010
 

How to cite this article:
Senthilkumaran S, Balamurgan N, Karthikeyan V, Thirumalaikolundusubramanian P. Eschar- A forgotten focus of concern. J Global Infect Dis 2010;2:195-6

How to cite this URL:
Senthilkumaran S, Balamurgan N, Karthikeyan V, Thirumalaikolundusubramanian P. Eschar- A forgotten focus of concern. J Global Infect Dis [serial online] 2010 [cited 2019 Aug 18];2:195-6. Available from: http://www.jgid.org/text.asp?2010/2/2/195/62867


Sir,

Scrub typhus is an acute febrile illness usually endemic in many parts of Asia including India, caused by a microbe Rickettsia tsutsugamushi (R. orientalis) and transmitted to humans by the bite of larval stage of infected trombiculid mites or chiggers. Though transmission occurs throughout the year in tropical areas, in India the peak occurs between October and February. [1] At the site of mite bite, an eschar of 5-20 mm in diameter develops. The occurrence varies from 46 to 92%, and influenced by the complexion of the patient. In this letter we stress the importance of eschar in diagnosing the scrub typhus fever.

A 42-year-old male farmer was admitted with the history of fever and generalized body ache of three days duration. On examination he was conscious and febrile. His vitals were stable. He had icterus, axillary lymphadenopathy and a punched out ulcer with blackened scab, the eschar, below the right clavicle [Figure 1]. The vicinity of the eschar was surrounded by erythema. His Weil-Felix test was positive with OXK 320. Biochemical investigations revealed deranged liver and renal function tests. Fever work up for malaria, leptospirosis and enteric was negative. His blood and urine culture was sterile. He was diagnosed as a case of scrub typhus. He was managed with high flow oxygen, doxycycline, azithromycin and supportive care. He responded well to treatment.

The eschar begins as a small papule, then enlarges, undergoes central necrosis, and eventually acquires a blackened crust with an erythematous halo that resembles a cigarette burn. Necrotic eschar at the inoculating site of the mite is pathognomic of scrub typhus as shown in the picture. Eschar heralds the onset of symptoms invariably as observed in this case and usually occurs at sites where skin surfaces meet or clothes bind, such as the axilla, groin, neck, waist, and at in uncommon sites like wrist joint, elbow joint and inguinal area. [2] Although eschars are important in the diagnosis of scrub typhus, the lesions are painless and without any itching sensation in most cases, causing the infection goes undetected. Dong-min Kim et al. [3] have suggested assessing the presence of draining lymph node enlargement which could be an important adjuvant method for the diagnosis.

Physicians sometimes encounter eschar-like crust lesions in clinical practice which is similar to a scab formed after trauma, and its size may be very small, which also delays recognition of eschar in many cases. Under such circumstances it is essential to search for eschar carefully on entire body, and suspect scrub typhus as prompt treatment is necessary to decrease mortality in this disease. Lee et al. [4] used PCR method to arrive at early diagnosis using eschar material and has differentiated other eschar-like crusted lesions.


   Acknowledgment Top


Dr. K. Arthanari, M. S. for photography.

 
   References Top

1.Mathai E, Rolain JM, Varghese GM, Abraham OC, Mathai D, Raoult D. Outbreak of scrub typhus in southern india during the cooler months. Ann N Y Acad Sci 2003;990:359-64.  Back to cited text no. 1      
2.Aggarwal P, Mahesh DM, Ravi Kumar V, Himral P, Kaushal SS, Verma BS. Atypical eschar sites in scrub typhus in sub-Himalayas. J Assoc Physicians India 2009;57:154.  Back to cited text no. 2  [PUBMED]    
3.Dong-min Kim, Won KJ, Park MY, Yu KD, Kim HS. Distribution of eschars on the body of scrub typhus patients: a Prospective Study. Am J Trop Med Hyg 2007;76:806-9.  Back to cited text no. 3      
4.Lee SH, Kim DM, Cho YS, Yoon SH, Shim SK. Usefulness of eschar PCR for diagnosis of scrub typhus. J Clin Microbiol 2006;44:1169-71.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
S Senthilkumaran
Department of Accident, Emergency & Critical Care Medicine, Sri Gokulam Hospital & Research Institute, Salem, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-777X.62867

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This article has been cited by
1 Predictors of scrub typhus: a study from a tertiary care center
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