Q J Med 2015; 108:347 doi:10.1093/qjmed/hcu209

Advance Access Publication 29 September 2014

Clinical picture The ‘cigarette burn’ sign Case presentation A 64-year-old man from an Indian dengue endemic area was admitted with 9 days history of fever, rashes and decreased urine output. Clinically, he was febrile with generalized macular rash over the body. On investigations, he had decreased platelet counts (60 000/mm3), increased hematocrit (52%) and increased serum urea and creatinine levels (108 and 3.8 mg%, respectively). He was treated empirically for dengue hemorrhagic fever, but his condition progressively deteriorated. On re-evaluation, he was found to have a papular lesion on right middle quadrant of his abdomen, 15 mm in diameter, with central blackened crust, resembling cigarette burn (Figure 1). Patient was totally unaware of this lesion. Based on provisional diagnosis of scrub typhus, doxycycline was started. The patient’s condition improved dramatically within 3 days of treatment. The diagnosis of scrub typhus was confirmed by Weil Felix test.

Scrub typhus: tsutsugamushi disease Scrub typhus is caused by Orientia tsutsugamushi, a Gram-negative coccobacillus. It is endemic in Asia– Pacific region with incidence of 1 million cases/ year.1 It has varied clinical spectrum, and apart from constitutional symptoms, patient often present with shock, thrombocytopenia, hepatitis, Acute Respiratory Distress Syndrome or CNS manifestations. Eschar is the pathognomic sign, which appears at the site of thrombiculid mite bite.2,3 Immunofluorescence assay is the gold standard, but Weil-Felix test and scrub typhus IgM ELISA are more commonly used diagnostic modalities.2,3 Doxycycline is the drug of choice.1,4

Cigarette burn mark: hidden clue The eschar resembling ‘cigarette burn mark’ is seen in 95% of cases and is most important diagnostic clue of scrub typhus.4 It often goes unnoticed by both the physician and patient. Patients are often unaware of this mark as it is painless and non-itching. Early

Figure 1. Eschar with central dark necrotic crust, resembling cigarette burn.

diagnosis by carefully examining the patient and prompt treatment is necessary as delay in treatment can result in life-threatening complications.2 Photographs and text from: Dr S. Sharma, Department of Medicine, PGIMER, Dr RML Hospital, New Delhi, India. email: [email protected] Conflict of interest: None declared.

References 1. Botelho-Nevers E, Raoult D. Fever of unknown origin due to rickettsioses. Infect Dis Clin North Am 2007; 21:997–1011. 2. Mahajan SK, Kashyap R, Kanga A, Sharma V, Prasher BS, Pal LS. Relevance of Weil-Felix test in diagnosis of scrub typhus in India. J Assoc Physicians India 2006; 54:619–21. 3. Kim DM, Won KJ, Park CY, Yu KD, Kim HS, Yang TY, et al. Distribution of eschars on the body of scrub typhus patients: a prospective study. Am J Trop Med Hyg 2007; 76:806–9. 4. Jeong YJ, Kim S, Wook YD, Lee JW, Kim KI, Lee SH. Scrub typhus: clinical, pathologic, and imaging findings. Radiograph 2007; 27: 161–72.

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The 'cigarette burn' sign.

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