Afebrile scrub typhus (Tsutsugamushi disease) with acute respiratory distress syndrome

A 74-year-old Japanese man with scrub typhus presented without the typical symptom of high fever and subsequently developed the complication of acute respiratory distress syndrome. It was suspected that exposure occurred at the river side of Kinugawa, Tochigi Prefecture, Japan. His body temperature was below 38.0degreesC. After intensive supportive care and minocycline therapy, he dramatically recovered. With the increase in popularity of outdoor recreation, scrub typhus can be found in clinics all over Japan. Physicians should therefore be aware of the manifestations of the disease and the necessity of early treatment in suspected cases.