Scrub Typhus Coinfection Research Articles

Scrub typhus-leptospirosis co-infection in India: a systematic review and meta-analysis.

Scrub typhus and leptospirosis are re-emerging zoonotic infections with significant morbidity and mortality rates in India. Overlapping aetiological and epidemiological patterns indicate a high possibility of their co-infection in India, which can be a diagnostic challenge due to non-specific clinical features. A systematic search of the PubMed/MEDLINE, Scopus and Embase databases was conducted to identify relevant studies published through 31 August 2023. Studies reporting co-infection of scrub typhus and leptospirosis among the Indian population were included. Data extraction, quality assessment and statistical analysis were performed in accordance with established guidelines. Six studies met the inclusion criteria, comprising a total of 58 co-infection cases. Pooled prevalence of scrub typhus-leptospirosis co-infection among acute undifferentiated febrile illness patients was 3.7% (95% confidence interval [CI] 0.00 to 0.126). Among scrub typhus patients, the prevalence of co-infection with leptospirosis was 13.7% (95% CI 0.027 to 0.304). Significant heterogeneity was observed among the included studies, highlighting the need for cautious interpretation of prevalence estimates. This meta-analysis underscores the clinical importance of scrub typhus-leptospirosis co-infection in India and emphasizes the need for enhanced clinical awareness, improved diagnostic strategies and targeted research efforts to address this emerging infectious disease threat.

Coinfection of Leptospirosis with Scrub Typhus: A Case Report

Leptospirosis and scrub typhus are common zoontic illnesses in tropical countries. Leptospira, a spirochaete, can cause leptospirosis when a patient comes in contact with contaminated water. Following a period of bacteraemic illness, leptospirosis may progress to a more severe form. Weil’s disease is a severe form of leptospirosis characterised by jaundice, haemorrhage and acute kidney injury. Scrub typhus, a rickettsial disease, common in South-East Asia is caused by Orientia tsutsugamushi occurs due to bite of Trombicula mite. An eschar forms at the site of the bite. Here we present a case of a 60-year-old gentleman, hailing from Savar who was diagnosed as a case of coinfection of scrub typhus and leptospirosis. Patient presented with an eschar, high grade fever and features of Weil’s disease. He didn’t initially respond to Ceftriaxone and then Doxycycline was added after which he became afebrile. J MEDICINE 2024; 25: 187-190

CLINICAL AND LABORATORY PROFILE OF ADMITTED PATIENTS PRESENTING WITH FEBRILE ILLNESS DUE TO DENGUE AND SCRUB TYPHUS COINFECTION FROM A TERTIARY CARE HOSPITAL IN SOUTH RAJASTHAN, INDIA

Objective: The present study aims at describing the clinical features, laboratory diagnosis, and complications in patients presenting with febrile illness due to scrub typhus and dengue coinfection from Southern Rajasthan, India. Method: This present prospective, observational, and hospital-based study conducted in the Department of Microbiology of AIMS & RC, Rajsamand, located in Southern Rajasthan, from January 2021 to December 2021. Scrub typhus was diagnosed in the microbiology laboratory by performing SD Bioline, one-step scrub typhus for the detection of IgM antibody, and dengue fever using J.mitra and Co. Pvt. Ltd., rapid card test for the detection of NS1 antigen and IgM antibody. Result: Out of 500 patients suspected of AUFI, 25 (5%) patients diagnosed of having dengue and scrub typhus coinfection. Fever was present in all 25 (100%) patients and 13 (52%) of patients had arthralgia, nausea, and vomiting. The most common sign noticed in our study was pallor and icterus in 10 (40%) patients each followed by shock/hypotension in 8 (32%) and hepatosplenomegaly in 5 (20%). The most predominant laboratory finding was thrombocytopenia (<1.0 × 106/cumm) in 23 (92%) patients, while elevated bilirubin (>2 mg/dl) in 22 (88%) and elevated transaminase and prolonged aPTT in 21 (84%) patients each. The majority of patients 23 (92%) had hepatic dysfunction, i.e., in followed by multi-organ dysfunction (MODS) in 15 (60%). Conclusion: In developing countries like India, particularly in tropical areas, dengue, and scrub typhus coinfection is under-recognized entity. Additional investigation should be carried out in cases of AUFI patients with features such as hypotension, leukocytosis, early drop in platelet counts, and hypoalbuminemia.

Leptospirosis and Scrub Typhus Coinfection of a 50-year-old male: A Case study

The bacterial diseases, leptospirosis and scrub typhus are important causes of acute febrile illness in India and are responsible for high morbidity and mortality. The common epidemiology of the zoonotic diseases creates an opportunity of dual infection. In this study, we describe a medical case of a 50-year-old male who was reported to have high grade fever for 10 days along with chills and coughs and was admitted to the RG Kar Medical College and Hospital on November last year. He was reported to suffer from conjunctival congestion, episode of pr bleeding, bowel and bladder incontinence, abdominal distension and pedal edema. Enzyme linked immunosorbent assay (ELISA) detected IgM antibodies to both leptospirosis and scrub typhus in the serum of the patient indicating dual infection with both bacterial diseases. Timely diagnosis of the patient followed by treatment with the antibiotics and associated medication resulted in complete recovery from both the diseases. As both leptospirosis and scrub typhus present with similar clinical features, co-infection of these two diseases is not uncommon. Cases of dual infections must be therefore considered seriously and choice of therapy should include those drugs that cover for both the infections.

SARS-CoV-2 Induced Multisystem Inflammatory Syndrome in Children (MIS-C) with Seropositive Scrub Typhus: A Case Series.

Statement of the problem: Pediatric patient with history of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was diagnosed with a serious condition called Multisystem Inflammatory Syndrome in Children (MIS-C). It is a post infectious excessive immune response differing from cytokine storm of SARS-CoV-2. MIS-C ranges from mild tosevere form, with multiorgan involvement viz, cardiac, gastrointestinal, renal, neurological, hematological etc.; and laboratory evidence of hyperinflammation. Scrub Typhus (ST), a mite borne rickettsial febrile zoonosis; has been reported in India and worldwide. It is caused by a gram-negative coccobacillus called Orientia tsutsugamushi and transmitted by the bite of chiggers, the infected larva of trombiculid mites (genus Leptotrombidium). ST present as a febrile illness with eschar and rash, but can manifest with a myriad of unusual presentations involving different organ system. Incidence of different organ involvement with rarity of association between these two conditions grew our interest on this case series.
 Methodology and Theoretical orientation: The study was conducted in the Pediatrics department of Malda Medical College and Hospital for a period of 6 months. All the subjects (age < 12 years) with complain of fever was evaluated for all tropical causes and among them the 3 child with
 
 a) Scrub Typhus IgM Ab Positive
 b) SARS-CoV-2 RTPCR Negative
 c) SARS-CoV-2 IgG antibody Positive
 d) MIS-C Positive (as per WHO’s definition) was included in the study. The 3 cases was clinically evaluated in details with signs, symptoms , laboratory parameters and treatment given.
 
 Findings: The CASE 1 and CASE 2 came with a neurological presentation on admission where as the CASE 3 presented with gastrointestinal one, fever being common in both. IV steroids, IVIg, Enoxaparin s/c were given to the patients but fever subsided with introduction of doxycycline after they became seropositive for scrub typhus. After thorough investigation it was found that both of them were positive for SARS-CoV-2 IgG antibody and Scrub Typhus IgM antibodywith features of MIS-C.
 Conclusion and Significance: Recently a seroprevalence study also reported a 5% co-infection of Scrub Typhus with seropositive MIS-C. The attribution of the co- infection in the Tsutsugamuschi Triangle with this clinical scenario and febrile presentation mimicking tropical diseases make this condition a circumstantial challenge. Pediatrician should be more vigilant while dealing with the febrile illness for early diagnosis and proper treatment of this condition.

Prevalence of Chikungunya and Scrub Typhus Coinfection among Dengue Negative Patients in Kolkata, India-A Newly Emerging Public Health Hazard

The chikungunya virus (CHIKV) and scrub typhus infection has scattered worldwide creating human health hazards in India and Asia specific region. We aimed to identify chikungunya, scrub typhus, and their co-infection in dengue-negative samples having undifferentiated febrile illnesses. Enzyme linked immunosorbent assay (ELISA) methods were used to detect the chikungunya and scrub typhus specific IgM antibody by using chikungunya IgM capture ELISA kit and scrub typhus IgM Microlisa ELISA kit, respectively. OD value was measured with the help of BeneSphera (India) ELISA microplate reader. Among 490 suspected patients, 57 (11.63%) samples were tested positive for chikungunya IgM antibodies, while 43 (8.77%) came positive for scrub typhus IgM antibodies, but all samples tested negative for dengue IgM antibodies. Additionally, 5% of the total positive cases were positive for both chikungunya and scrub typhus infection. Our study offers a hypothesis regarding one of the possible causes of the decline in the frequency of scrub typhus and chikungunya cases reported in Kolkata and other districts of West Bengal. As an outcome, physicians treating undifferentiated febrile patients in endemic locations should look for chikungunya, scrub typhus, and existing coinfection between them to avoid delayed diagnosis and provide proper treatment against these infections.

Recent cases of co-infection of scrub typhus and leptospirosis: A short clinical study

Scrub typhus and leptospirosis are bacterial zoonotic diseases causing high morbidity and mortality. Both are important causes of acute febrile illness in India. The common epidemiology of both the diseases creates an opportunity of dual infections with these diseases. The present study was conducted at RG Kar Medical College and Hospital to determine simultaneous infection of leptospirosis and scrub typhus in sera of febrile patients and evaluate the cases of serological dual infections. IgM antibodies to both leptospira and scrub typhus were detected by Enzyme linked immunosorbant assay (ELISA). During the study period (August 2022-October 2022), serum samples of patients were received for serology for scrub typhus. Out of these samples, 5 patients diagnosed for scrub typhus infection also had IgM antibodies to leptospira, thus indicating co-infection of both diseases. The current study adds further to few previously published reports on co-infection of scrub typhus with leptospirosis. As both leptospirosis and scrub typhus present with similar clinical features, co-infection of these two diseases is not uncommon and requires further confirmation at molecular level. Accordingly, cases of dual infections must be considered seriously and choice of therapy should include those drugs that cover for both the infections.

Recent cases of co-infection of scrub typhus and leptospirosis: A short clinical study

Recent cases of co-infection of scrub typhus and leptospirosis: A short clinical study

Dengue and scrub typhus co-infection in children: Experience of a teaching hospital in an endemic area

Dengue fever and scrub typhus are considered an endemic disease in the Indian subcontinent. The epidemiology and clinical presentations are complex and vary each year. The objective of this study was to estimate the prevalence of coinfection with scrub typhus in children diagnosed with dengue fever. A retrospective hospital-based, cross-sectional study was done in the Department of Pediatrics of a teaching hospital in Puducherry. All children (0-14 years) who had enzyme-linked immunosorbent assay (ELISA) reported scrub typhus among those diagnosed with dengue fever (NS1Ag or immunoglobulin M ELISA positivity) during 2012-2016. Medical records with incomplete data were excluded from the study. Odds ratio was calculated to find out the association of coinfections. An independent t-test was used to find out the statistical significance. P < 0.05 was considered statistically significant. Atypical features of dengue were present in 250/318 (78.6%) children. Coinfections were seen in 62/318 (19.4%) children. Scrub typhus was the most common (n = 51/62, 82.2%). The chance of scrub typhus in a dengue serology-positive child is significant when the symptoms are atypical or protracted (OR- 2.6, P = 0.033). High index of suspicion should be present in endemic dengue and scrub typhus coinfection.

Case Report: A Case of Co-Infection of Scrubtyphus and Cmv As An Acute Encephalitis Syndrome

Case Report: A Case of Co-Infection of Scrubtyphus and Cmv As An Acute Encephalitis Syndrome

Prevalence of malaria and scrub typhus co-infection in febrile patients: a systematic review and meta-analysis

BackgroundLittle information is available about malaria and scrub typhus co-infection. This study aimed to investigate the pooled prevalence of malaria and scrub typhus co-infection in febrile patients. Further, it aimed to estimate the prevalence of scrub typhus infection among patients with malaria and the odds of co-infection. This will aid the diagnosis and management of co-infected patients in endemic areas.MethodsWe searched for relevant studies in three databases: PubMed, Scopus, and Web of Science. We assessed the quality of the included studies using the Joanna Briggs Institute checklist for analytical cross-sectional studies. We estimated (1) the pooled prevalence of malaria and scrub typhus co-infection, (2) the pooled prevalence of scrub typhus infection in malaria-positive patients, and (3) the pooled odds of co-infection using the DerSimonian–Laird method for random-effects models. The study results and summary estimates were visualized on a forest plot as point estimates (effect size, prevalence) and 95% confidence intervals (CI). We assessed the heterogeneity of the studies by Cochrane Q or I2 statistics. We performed subgroup analyses of countries and scrub typhus diagnostic tests to explore the sources of heterogeneity of the included studies. We assessed publication bias if more than 10 studies were used to estimate the outcome. All data analyses were conducted using Stata version 14 (StataCorp, College Station, TX, USA).ResultsOf the 542 studies retrieved from three databases, we included 14 meeting the inclusion criteria in the systematic review and meta-analysis. The pooled prevalence of malaria and scrub typhus co-infection (56 cases) among febrile patients (7920 cases) was 1% (95% CI: 0–1%, I2: 78.28%), while the pooled prevalence of scrub typhus infection (321 cases) in patients with malaria (1418 cases) was 21% (95% CI: 12–30%, I2: 98.15%). Subgroup analysis showed that the pooled prevalence of scrub typhus infection among patients with malaria in India was 8% (95% CI: 4–13%, I2: 85.87%, nine studies with 59/794 cases), while the pooled prevalence of scrub typhus infection among patients with malaria in Thailand was 35% (95% CI: 7–64%, I2: 98.9%, four studies with 262/624 cases). The co-infections did not occur by chance (P = 0.013, odds: 0.43, 95% CI: 0.22–0.84%, I2: 60.9%). In the sensitivity analysis, the pooled prevalence of malaria and scrub typhus co-infection among febrile patients was 0% (95% CI: 0–1%, I2: 59.91%).ConclusionsThe present study showed the pooled prevalence and a significant association between malaria and scrub typhus. The results show the status of co-infection. Further research into co-infection in endemic areas is needed, in particular, to determine whether co-infection can accelerate disease progression or protect against severe disease.Graphical abstract

Hemophagocytic Lymphohistiocytosis Associated with Coinfection of Scrub Typhus and Dengue Fever in a Child: A Case Report

Hemophagocytic Lymphohistiocytosis Associated with Coinfection of Scrub Typhus and Dengue Fever in a Child: A Case Report

Comparative Study of Chikungunya Only and Chikungunya-Scrub Typhus Coinfection in Children: Findings from a Hospital-Based Observational Study from Central Nepal.

Objectives Chikungunya and scrub typhus infection are important causes of undifferentiated fever in tropical zones. The clinical manifestations in both conditions are nonspecific and often overlap. This study compares the clinical manifestations and the outcome of chikungunya with chikungunya-scrub typhus coinfection in children. Methods A hospital-based observational study was conducted in children below 15 years of age over 16-month duration in 2017-2018. Chikungunya was diagnosed by IgM ELISA. All positive chikungunya cases were subjected to scrub typhus testing, dengue testing, leptospira testing, and malaria testing. Clinical manifestations and outcomes of all patients were recorded. Results Out of the 382 admitted cases with fever, 11% (n = 42) were diagnosed with chikungunya, and the majority (n = 30, 71.4%) were male. Among the 42 chikungunya cases, 17 (40.5%) tested positive for scrub typhus and one positive for falciparum malaria. Out of a total of 42 chikungunya cases, myalgia, nausea/vomiting, headache, abdominal pain, lymphadenopathy, hepatomegaly, splenomegaly, and edema were 81%, 73.8%, 66.7%, 64.3%, 59.5%, 52.4%, 40.5%, and 38.1%, respectively. Besides, altered sensorium (31%), jaundice (26.2%), dry cough (21.4%), shortness of breath (19%), and seizures (16.7%) were other clinical manifestations present in this group of children. Patients with chikungunya-scrub typhus coinfection reported headaches, pain in the abdomen, dry cough, shortness of breath, seizures, and splenomegaly, significantly more (p value < 0.05) compared to those with chikungunya only. Thirteen (31%) children developed shock, five in the chikungunya group and eight in the chikungunya-scrub typhus coinfection group. Six children in the coinfection group received inotrope. Among the chikungunya-only cases, 22 recovered and one died, whereas in the chikungunya-scrub typhus coinfection group, fourteen recovered and three died. Conclusions Both the chikungunya and scrub typhus coinfection groups shared many similar clinical manifestations. In children, coinfection with scrub typhus often leads to modification of the clinical profile, complications, and chikungunya outcome.

Misdiagnosis of scrub typhus as hemorrhagic fever with renal syndrome and potential co-infection of both diseases in patients in Shandong Province, China, 2013-2014.

BackgroundScrub typhus, caused by Orientia tsutsugamushi, an obligate intracellular gram-negative bacterium, along with hemorrhagic fever with renal syndrome (HFRS), caused by hantaviruses, are natural-focus infectious diseases prevalent in Shandong Province, China. Both diseases have similar clinical manifestations in certain disease stages and similar epidemic seasons, which has caused difficulties for physicians in distinguishing them. The aim of this study was to investigate whether misdiagnosis of scrub typhus as HFRS occurred in patients in Shandong Province.MethodsSerum samples (N = 112) of clinically suspected HFRS patients from 2013 to 2014 in Shandong Province were analyzed with enzyme-linked immunosorbent assay (ELISA) for antibodies to both hantavirus and Orientia tsutsugamushi.ResultsELISA showed that 56.3% (63/112) and 8.0% (9/112) of clinically suspected HFRS patients were IgM antibody positive to hantavirus and O. tsutsugamushi, respectively. Among the hantavirus IgM antibody positive patients, 7.9% (5/63) were also IgM antibody positive to O. tsutsugamushi. Among the hantavirus IgM antibody negative sera, 8.2% (4/49) of sera were positive to O. tsutsugamushi.ConclusionsWe concluded that some scrub typhus patients were misdiagnosed as HFRS and co-infection of scrub typhus and HFRS might exist in China. Due to the different treatments for scrub typhus and HFRS, physicians should carefully differentiate between scrub typhus and HFRS and consider administering anti-rickettsia antibiotics if treatment for HFRS alone does not work.

Co-infection of scrub typhus and COVID-19: A diagnostic challenge

Scrub typhus is a bacterial disease, caused by Orientia tsutsugamushi and has widespread clinical presentations. Coronavirus-19 disease (COVID-19) is an ongoing pandemic, which can demonstrate clinical symptoms similar to the scrub typhus. Herein, we are describing two such cases of scrub typhus and COVID-19 co-infection. A 35-year-old male and a 42-year-old female presented with respiratory failure, for which COVID-19 was diagnosed, but both of them had persistent thrombocytopenia. The patients were investigated for other tropical co-infections and the diagnosis of scrub typhus was established in both of the cases. Doxycycline was added to their ongoing treatment, which led to an uneventful recovery. The cases highlight the importance of keeping a high index of suspicion of concurrent infection in the regions where seasonal tropical infections are endemic.

A descriptive study of seasonal influenza cases in a single season in a tertiary center in Kathmandu

Introduction: This is a clinic-epidemiological study of the total cases of polymerase chain reaction (PCR) confirmed influenza cases. We aim to characterize the disease, its morbidities and mortality. Materials and Methods: The details of all PCR confirmed influenza (H1N1) cases were obtained from the hospital records and descriptive statistical analysis tools were used to report the findings. Results: A total of 35 cases were confirmed as influenza from January to March 2019. The most common presenting complaints were fever (91%), cough (85%) and shortness of breath (65%). The most frequent diagnosis made was pneumonia (88%). Septic shock was present in 29% while 14% had acute kidney injury (AKI). Oxygen therapy was required in 71% with 17% requiring mechanical ventilation and another 11% requiring non-invasive ventilation. Fourteen percent had developed severe acute respiratory distress syndrome (ARDS) requiring proning. A total of 77% patients were successfully discharged home, 8% were transferred to other centers on request for various reasons and 11% were withdrawn from all active treatment leading to death. One patient was taken home against advice whose outcome could not be traced. During treatment, two patients had developed ischemic stroke, two required haemodialysis for acute renal failure and other two had scrub typhus co-infection. Conclusions: A total of 85% of the patient survived while the rest lost their lives. The most important factor recognized was the financial burden associated with the treatment. Diagnostic delays and limited supply of Oseltamivir might be the other barriers in the treatment of the disease.

Dengue with Scrub Typhus Coinfection in Northern India

Background: Amongst the many vector and water-borne diseases prevalent in tropics, dengue occupies a prominent place. Dengue epidemics are frequent and at times, during such epidemic, coinfections may occur causing diagnostic dilemmas.&#x0D; Case Report: A 36 years old lady, from a rural background, presented during the 2019 dengue epidemic with fever, vomiting, and non-colicky abdominal pain. The evaluation showed hepatosplenomegaly, leukocytosis, and thrombocytopenia. The investigations confirmed the diagnosis and she was treated conservatively as a case of dengue with warning signs. A longer than anticipated duration of fever and clinical deterioration prompted reassessment, which revealed the presence of an eschar over the right upper thigh. The Weil-Felix test using Proteus OX-K stain was positive at a titer of 1:320. Following treatment with oral doxycycline, she showed rapid defervescence and clinical improvement.&#x0D; Conclusions: Coinfection with scrub typhus is rare with dengue. If left untreated, it adversely affects the outcome. The key to diagnosing such coinfections includes a high index of suspicion, repeated clinical examination, and the knowledge of local endemicity.

Co-Infection of Scrub Typhus and Hemorrhagic Fever with Renal Syndrome in Shandong Province, China, 2013-2014

Background: Scrub typhus caused by Orientia tsutsugamushi, an obligatory intracellular bacterium, and hemorrhagic fever with renal syndrome (HFRS) caused by hantavirus are natural-focus infectious diseases prevalent in Shandong Province, China. Both diseases have similar clinical manifestations in certain disease stages and similar epidemic seasons, which caused difficulties for physicians to distinguish them correctly. The aim of this study was to investigate whether misdiagnosis or co-infection of scrub typhus and HFRS existed in Shandong Province. Methods: We analyzed 112 serum samples of clinically diagnosed HFRS patients from 2013 to 2014 in Shandong Province with enzyme-linked immunosorbent assay (ELISA). Findings: ELISA showed that 56·3% (63/112) and 8·0% (9/112) of clinically diagnosed HFRS patients were IgM antibody positive to hantavirus and O. tsutsugamushi, respectively, suggesting that these IgM antibody positive patients were infected with hantavirus or O. tsutsugamushi. Among the confirmed HFRS patients who were IgM antibody positive to hantavirus, 7·9% (5/63) were also IgM antibody positive to O. tsutsugamushi, suggesting that these patients were co-infected with hantavirus and O. tsutsugamushi. Among the hantavirus IgM antibody negative sera, 8·2% (4/49) of sera were positive to O. tsutsugamushi, suggesting these patients were infected with O. tsutsugamushi. We concluded that a large portion of HFRS patients were co-infected with scrub typhus and some scrub typhus patients were misdiagnosed as HFRS. Interpretations: Due to the different treatments for scrub typhus and HFRS, physicians should carefully differentiate between scrub typhus, HFRS, and co-infection of both diseases for better treatment of patients. Funding Statement: National Natural Science Funds (China). Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: Ethical approval of this study was admitted by the ethics committees of Wuhan University.

Development of multiplex PCR for neglected infectious diseases.

Scrub typhus, murine typhus, and leptospirosis are widely neglected infectious diseases caused by Orientia tsutsugamushi, Rickettsia typhi, and pathogenic Leptospira spp., respectively. Patients usually present with non-specific symptoms and therefore are commonly diagnosed with acute undifferentiated febrile illness. Consequently, patients face delayed treatment and increased mortality. Antibody-based serological test currently used as gold standard has limitations due to insufficient antibody titers, especially in the early phase of infection. In this study, we aimed to develop multiplex PCR to combine 3 primer pairs that target specific genes encoding 56-kDa TSA of O. tsutsugamushi, 17-kDa antigen of R. typhi, and LipL32 of L. Interrogans and evaluate its performance in comparison to the standard serological tests. Using EDTA blood samples of known patients, the sensitivity and specificity of our multiplex PCR was 100% and 70%, respectively. In addition, the assay was able to diagnose the co-infection of scrub typhus and leptospirosis. The assay may be useful in identifying causative agents during the early phase of these diseases, enabling prompt and appropriate treatment.

Melioidosis and scrub typhus co-infection in a patient presenting with acute undifferentiated febrile illness

Melioidosis and scrub typhus are endemic diseases in Malaysia. However, unlike melioidosis, scrub typhus is more difficult to be diagnosed and in Malaysia its true disease burden is unknown. We report a case of severe melioidosis and scrub typhus co-infection in a patient living in a small village in Peninsular Malaysia whom presented with fever and headache. This case highlights the importance of considering scrub typhus as a diagnostic possibility in cases of acute undifferentiated febrile illness in rural areas such as that of in Peninsular Malaysia.