Hemophagocytic Lymphohistiocytosis (HLH) Secondary to Scrub Typhus: an Unusual Presentation

REPORTimmunoglobulin M for scrub typhus (2.99, cutoff-1.2).She was started on injection (inj) doxycycline as per the recommendation for scrub typhus management.The rest of the tropical workup was negative.The blood picture showed bicytopenia, especially a drop in neutrophils and platelet counts.There was no evidence of coagulopathy or abnormal cells.Because of ongoing bicytopenia, and persistent fever, the HLH, a rare association, was contemplated on day 17 of illness and day 2 of admission and doxycycline therapy.Further reports were serum ferritin of 14048 ng/mL, plasma fibrinogen-77 mg/dL, isolated hypertriglyceridemia of 337 mg/ dL, and D-dimer-14439 ng/mL.In view of a very high H score for reactive hemophagocytic syndrome-223 with a 96-98% probability of hemophagocytic syndrome, she was started on inj dexamethasone 8 mg two times a day on day 3 of admission.Subsequently, a bone marrow biopsy was done, revealing abnormally increased histocytes 1,3,