Scrub Typhus Complicated With Fulminant Perimyocarditis

Abstract

A 62-year-old woman with no systemic disease presented to the emergency department (ED) with acute febrile illness for three days. During her ED course, she developed respiratory distress and refractory cardiogenic shock with ST-elevation on electrocardiography. No occluded coronary vessel was found in angiography, and perimyocarditis was impressed. The serum indirect immunofluorescence assay was positive for scrub typhus. Hemopericardium and subsequently intracranial hemorrhage occurred on the 4th hospital day even under intensive care, and the patient expired. Perimyocarditis is a rare but fatal complication of scrub typhus. Through this case report, we aim to convey the genuine possibility that a fulminant perimyocarditis may occur in a previously healthy adult as a potential complication of scrub typhus. By recognizing the risk factors of scrub typhus-related myocarditis, an ED physician can maintain a high index of suspicion for the cardiac complication and intervene in a timely manner.

Keywords: cardiogenic shock; perimyocarditis; scrub typhus.

Figure 1. Photograph showing 1.0 x 0.6 cm eschar in the right axilla region.

Figure 2A. Chest radiograph at the time of admission and six-hour later.

(A) The initial chest radiograph revealed mild bilateral pleural effusion.

Figure 2B. Chest radiograph at the time of admission and six-hour later.

(B) Second chest radiography of six hours later revealed bilateral enlarged hilar shadows with lung infiltrations and patchy densities.

Figure 3A. Electrocardiography at the time of admission and six-hour later.

(A) Initial electrocardiography revealed sinus tachycardia.

Figure 3B. Electrocardiography at the time of admission and six-hour later.

(B) Second electrocardiography of six hours later revealed anterior ST-segment elevation.

Figure 4. The image of aortic computed tomography angiography revealed acute fulminant perimyocarditis with inflamed/infectious epicardial and hypervascular tissue overlying apical left ventricle.