Soumyabrata Roy Chaudhuri^1,, Deep Das², Hindol Dasgupta³, Dipnarayan Mukherjee⁴, Kingshuk Bhattachacharjee⁵

Scrub typhus is an acute febrile illness which has varied manifestation from febrile illness to a more severe multi-organ dysfunction including CNS involvement in the form of meningitis and meningoencephalitis and in extremes cases, septic shock and death. Scrub typhus is prevalent in India and there have been reported case series from north-eastern regions of India and also from various institutes of south India. In sharp contrast, our case is a single incidence and classically showed features of lung involvement which predisposes to CNS involvement (in the form of meningitis or meningoencephalitis) later. All the published case reports/series from the subcontinent, it is unanimously stated that response is dramatic upon starting of oral doxycycline and the clinical scenario changes within 48- 72 hours. However in this anecdotal case of ours, intravenous doxycycline was started and still patient went downhill before he stabilised after 10 days of the therapy. Although doxycycline failures have been reported from Korea and the medical scientists have put forward their explanations about the questionable emerging resistance to doxycycline, still this case remains important because it is one of the first reported cases from the Indian subcontinent where the clinical features deteriorated even after starting Doxycycline ("The erstwhile gold standard antibiotic against Scrub Typhus) and that too via intravenous route. The case presents a dilemma in the minds of the clinician as to what strategy may be taken to achieve higher MIC values of Doxycycline (to overcome the emerging resistance) and also triggers the search for new antibiotic regimen which can help us to control scrub typhus early and prevent the more severe and life threatening complications of the disease.

scrub typhus, meningoencephalitis, doxycycline resistance, dual seropositivity, India