A 57-year-old man was admitted to our hospital for general weakness, gait disturbance, and mental change. He had visited a family member's grave 1 month previously. For 3 days before admission, the patient experienced a febrile sensation and skin rash. He had no previous history of medical diseases, such as diabetes mellitus, hypertension, or tuberculosis. Physical examination showed a temperature of 37.4℃, blood pressure of 120/70 mm Hg, and pulse rate of 70/min. Eschars were noted over the upper portion of his left arm and back. A neurologic examination indicated that his consciousness ranged from a stupor to a semicomatose state. He did not show motor responses and had a sluggish light reflex. He did not have cranial nerve palsy. Results of the routine hematology test were normal, except for elevated fibrin degradation product (5.0 µg/mL) and D-dimer levels (1.57 µg/mL fibrinogen equivalent units). The liver function test showed an albumin level of 3.4 g/dL (range: 3.8-5.3 g/dL), total bilirubin level of 0.6 mg/dL (range: 0.2-1.0 mg/dL), alkaline phosphatase level of 362 U/L (range: 104-338 U/L), aspartate aminotransferase (AST) level of 812 U/L (range: 10-33 U/L), and alanine aminotransferase (ALT) level of 1043 U/L (range: 4-50 U/L). The C-reactive protein (CRP) level was 3.76 mg/dL (-0.5 mg/dL), and the erythrocyte sedimentation rate was 24 mm/h (range: 0-20 mm/h). Serologic tests yielded negative results for the hepatitis B surface antigen, human immunodeficiency virus, Hantan virus, Epstein-Barr virus, and cytomegalovirus. Polymerase chain reaction test results for the Epstein-Barr virus, cytomegalovirus, and tuberculosis were negative. CSF analysis showed a white blood cell count of 220/mm³ (lymphocytes 30%, polymorphonucleocytes 70%), glucose level of 66 mg/dL (blood glucose, 133 mg/dL), and protein level of 138.5 mg/dL (range: 11-45 mg/dL). The CSF sample tested positive for the tsutsugamushi antibody [immunoglobulin (Ig)-G, 1:160] and serum sample (IgG, 1:10240). Chest computed tomography showed patchy consolidations in the lower lobes of both lungs. On admission magnetic resonance images (MRIs), T2-weighted images (T2WIs), and fluid-attenuated inversion recovery images (FLAIRs) demonstrated multifocal, hyperintense lesions involving the cerebral white matter of both the right and left sides, thalamus, brainstem, left middle cerebellar peduncle, and both cerebellar hemispheres (Fig. 1). These lesions did not show contrast enhancement on contrast-enhanced T1-weighted images. On a follow-up MRI, obtained 5 days after admission, the extent of multiple areas of T2 hyperintense cerebral white matter lesions on both the right and left sides were slightly increased, with no significant interval change in the other sites. After treatment with doxycycline for 2 weeks, his consciousness improved to an alert state. However, his motor functions were still impaired in the left upper (grade 2/5), left lower (grade 3/5), right upper (grade 1/5), and right lower (grade 1/5) extremities. A follow-up MRI, acquired 2 weeks after admission, previously noted that the number of multifocal T2 hyperintense lesions had slightly decreased in the cerebral white matter on both sides and increased in the brainstem (Fig. 1). However, no significant interval changes were seen in the other lesion sites. He was discharged to a local hospital for rehabilitative therapy.

A 71-year-old woman was admitted to our hospital for general weakness. The patient had visited the countryside to pick persimmons 4 days previously. Three days before admission, she had visited a local hospital because of fever and general weakness. Her symptoms had not improved, and she presented with irritability on admission. She had a history of osteoporosis and hyperlipidemia, and was taking cholesterol-lowering medication. Physical examination showed a temperature of 36.5℃, blood pressure of 130/80 mm Hg, and pulse rate of 80/min. The patient did not have eschars, but she presented with ecchymosis and pain in both arms. Cranial nerve function was essentially normal. The patient did not present with abnormal motor function. Results of the routine hematology test were normal. The liver function test showed an albumin level of 4.0 g/dL (range: 3.8-5.3), total bilirubin level of 0.7 mg/dL (range: 0.2-1.0 mg/dL), alkaline phosphatase level of 240 U/L (range: 104-338 U/L), AST level of 254 U/L (range: 10-33 U/L), and ALT level of 52 U/L (range: 4-50 U/L). The creatine phosphokinase level was 11875 U/L (range: 38-176 U/L), and the CRP level was 0.23 mg/dL (-0.5 mg/dL). Serologic tests yielded negative results for the Hantan virus antibody, influenza A and B viral antigens, Cryptococcus antigen, varicella zoster virus, and human T-lymphotropic virus I/II. Polymerase chain reaction test results for the varicella zoster virus, herpes simplex virus, and tuberculosis were negative. The CSF and serum samples tested positive for the tsutsugamushi antibody (IgG, ≥ 1:160 and IgG, 1:640, respectively). Chest radiography showed no significant abnormality in both lungs. She was diagnosed with rhabdomyolysis and scrub typhus. After discontinuing the cholesterol-lowering medication, doxycycline was administered on the day following admission. Levels of the liver function enzymes and creatine phosphokinase improved, and the ecchymosis of both arms improved. However, her consciousness suddenly altered. CSF analysis showed a white blood cell count of 25 mm³ (lymphocytes 90%, polymorphonucleocytes 10%), glucose level of 46 mg/dL (blood glucose, 154 mg/dL), and protein level of 115.4 mg/dL (range: 11-45 mg/dL). Contrast-enhanced T1-weighted images showed focal parenchymal enhancement involving the right gyrus rectus and subtle subependymal enhancement along both lateral ventricles (Fig. 2). These lesions did not show a signal change on T2WIs and FLAIRs. We initiated treatment with a combination of doxycycline and rifampin. However, a follow-up MRI acquired 3 days later showed more prominent subependymal enhancement along both lateral ventricles. Another follow-up MRI, obtained 10 days later, after persistent medical therapy, showed that the subependymal enhancement along both the lateral ventricles had disappeared and new multifocal T2 hyperintense lesions appeared in both the basal ganglia and right frontal lobe (Fig. 2). The patient's mental status improved slightly (to a stupor) and she was transferred to another local hospital.