Volume 99, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Scrub typhus and Japanese spotted fever—both rickettsial diseases—are endemic and notifiable in Japan and may cause a fatal outcome without prompt treatment. Here we present the first case of a concurrent sympatric infection of both diseases with grade II evidence. A 67-year-old woman, after a single event of potential exposure to the pathogens, presented with a 12-day history of fever, pharyngeal pain, papulo-erythematous rash, and pronounced fatigue. Her erythematous rash was distributed on her trunk and extremities, palms, and soles and eventually progressed to purpura. Fever persisted until doxycycline was administered on day 12. A significant > 4-fold increase in immunoglobulin G and immunoglobulin M titers against multiple serotypes of and were revealed by indirect immunoperoxidase assays. These clinical and serological data, even in the absence of molecular or isolation evidence, provided grade II evidence that this was a concurrent infection of sympatric scrub typhus and Japanese spotted fever.


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  1. National Institute of Infectious Diseases J, 2017. Scrub typhus and Japanese spotted fever in Japan 2007–2016. Infectious Agent Surveillance Report (IASR). Tokyo, Japan: National Institute of Infectious Diseases and Tuberculosis and Infectious Diseases Control Division, Ministry of Health, Labour and Welfare, 109124. [Google Scholar]
  2. Taylor AJ, Paris DH, Newton PN, , 2015. A systematic review of mortality from untreated scrub typhus (Orientia tsutsugamushi). PLoS Negl Trop Dis 9: e0003971. [Google Scholar]
  3. Yasunaga H, Horiguchi H, Kuwabara K, Hashimoto H, Matsuda S, , 2011. Delay in tetracycline treatment increases the risk of complications in tsutsugamushi disease: data from the Japanese diagnosis procedure combination database. Intern Med 50: 3742. [Google Scholar]
  4. Ogawa M, Ono T, , 2008. Epidemiological characteristics of tsutsugamushi disease in Oita Prefecture, Japan: yearly and monthly occurrences of its infections and serotypes of its causative agent, Orientia tsutsugamushi, during 1984–2005. Microbiol Immunol 52: 135143. [Google Scholar]
  5. Ogawa M, 2002. Scrub typhus in Japan: epidemiology and clinical features of cases reported in 1998. Am J Trop Med Hyg 67: 162165. [Google Scholar]
  6. Paris DH, Dumler JS, , 2016. State of the art of diagnosis of rickettsial diseases: the use of blood specimens for diagnosis of scrub typhus, spotted fever group rickettsiosis, and murine typhus. Curr Opin Infect Dis 29: 433439. [Google Scholar]
  7. Phommasone K, Paris DH, Anantatat T, Castonguay-Vanier J, Keomany S, Souvannasing P, Blacksell SD, Mayxay M, Newton PN, , 2013. Concurrent infection with murine typhus and scrub typhus in southern Laos–the mixed and the unmixed. PLoS Negl Trop Dis 7: e2163. [Google Scholar]
  8. Sando E, Ariyoshi K, Fujita H, , 2018. Serological cross-reactivity among Orientia tsutsugamushi serotypes but not with Rickettsia japonica in Japan. Trop Med Infect Dis 3: 74. [Google Scholar]
  9. Kaiho I, Tokieda M, Tanaka H, Kawamura A, , 1992. Spotted fever group rickettsiosis in Chiba Prefecture. Kansenshogaku Zasshi 66: 201205. [Google Scholar]
  10. Kaiho I, Tokieda M, Yoshida Y, Furuya Y, Murata M, Tanaka H, Kawamura A, Jr., 1993. Epidemiology of tsutsugamushi disease and typing of isolated Rickettsia in Chiba Prefecture. Kansenshogaku Zasshi 67: 196201. [Google Scholar]
  11. Mori K, Fujimagari M, , 1993. The circumstance of collectinglxodid ticks on cities, towns and villages in Chiba Prefecture. Bull Public Health Lab Chiba Prefecture 17: 3740. [Google Scholar]
  12. Suzuki T, Nanayama Y, Sasa M, Tanaka H, Hayashi S, Suzuki T, Wakasugi M, Miura A, Ogata K, , 1955. Studies on scrub typhus in Chiba Prefecture. V: Seasonal occurrence of the trombiculid mites in southern part of Boso Peninsula. Med Entomol Zool 6: 6975. [Google Scholar]
  13. Zhang LJ, Li XM, Zhang DR, Zhang JS, Di Y, Luan MC, Fu XP, , 2007. Molecular epidemic survey on co-prevalence of scrub typhus and marine typhus in Yuxi city, Yunnan province of China. Chin Med J (Engl) 120: 13141318. [Google Scholar]
  14. Mahara F, , 1997. Japanese spotted fever: report of 31 cases and review of the literature. Emerg Infect Dis 3: 105111. [Google Scholar]
  15. Mahara F, , 2006. Rickettsioses in Japan and the far east. Ann NY Acad Sci 1078: 6073. [Google Scholar]
  16. Paris DH, 2015. A nonhuman primate scrub typhus model: protective immune responses induced by pKarp47 DNA vaccination in cynomolgus macaques. J Immunol 194: 17021716. [Google Scholar]
  17. Tachibana N, Kusune E, Yokota T, Shishime E, Tsuda K, Oshikawa T, , 1982. Epidemiological, immunological and etiological study on tsutsugamushi disease in Miyazaki district. Kansenshogaku Zasshi 56: 655663. [Google Scholar]
  18. Bourgeois AL, Olson JG, Fang RC, Huang J, Wang CL, Chow L, Bechthold D, Dennis DT, Coolbaugh JC, Weiss E, , 1982. Humoral and cellular responses in scrub typhus patients reflecting primary infection and reinfection with Rickettsia tsutsugamushi. Am J Trop Med Hyg 31: 532540. [Google Scholar]
  19. Suto T, , 1985. Evidence of spotted fever rickettsial infection in Japan as demonstrated by the indirect immunoperoxidase test. Microbiol Immunol 29: 12431246. [Google Scholar]

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  • Received : 26 Mar 2018
  • Accepted : 17 Aug 2018
  • Published online : 08 Oct 2018

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