Tsutsugamushi disease is transmitted through a mite bite. During the inoculation period, which typically lasts for 6 to 20 days, the patient usually remains asymptomatic. Approximately at the tenth day following the initial infection, high fever, headaches, myalgia and fatigue emerge. The non-specificity of the symptoms constitutes a diagnostic obstacle at the early disease phase. During this initial period, a papule begins to form at the region of the mite bite, gradually progressing to form a necrotic localized spot, referred to as an eschar.

Despite the diagnostic challenge due to the non-specificity of the symptoms, the existence of an eschar is pathognomonic of tsutsugamushi disease; it is observed in half of the patients with a primary infection and is well-defined by the time that an individual develops fever [1] [2] [3]. Other symptoms associated with tsutsugamushi disease are lymphadenopathy, regional or generalized, ocular pain, a productive cough and infected conjunctiva [4] [5]. A characteristic symptom is also the centrifugal macular rash that appears after approximately a week following the infection. The erythema develops on the torso, may gradually assume papular characteristics and may not be observed due to its transient nature [6].

As the disease progresses, pneumonia, encephalitis, delirium and splenomegaly may be added to the clinical picture.

• Splenomegaly

  As the eschar heals, there is a sudden onset of headache, malaise, anorexia, weakness, and fever, followed by pneumonia, a macular rash (on the trunk before the limbs), lymphadenopathy, hepato-splenomegaly, and conjunctivitis. [histopathology-india.net]

  As the disease progresses, pneumonia, encephalitis, delirium and splenomegaly may be added to the clinical picture. [symptoma.com]

  Splenomegaly may be present, and interstitial myocarditis is more common than in other rickettsial diseases. In untreated patients, high fever may persist ≥ 2 weeks, then falls gradually over several days. [msdmanuals.com]

  Splenomegaly is observed in 1/3 of cases. Most cases are mild, but pneumonitis, meningoencephalitis, multiorgan failure, bleeding and even death may occur, especially in untreated patients. [orpha.net]

• Generalized Lymphadenopathy

  All five children had fever, vomiting and generalized lymphadenopathy, but none had eschar or rash. One was cured with doxycycline, remaining four patients treated with azithromycin and one died despite treatment. [ncbi.nlm.nih.gov]

  After an incubation period of 6 to 21 days (mean 10 to 12 days), symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy. [msdmanuals.com]

• Fever

  Tsutsugamushi tsutsugamushi disease bush typhus Japanese river fever Kedani fever scrub mite-borne typhus Japanese river fever (disorder) Kedani fever (disorder) Scrub mite-borne typhus (& various types) Scrub typhus Scrub typhus (disorder) Scrub typhus [wikidata.org]

  Synonym(s): akamushi disease, flood fever, inundation fever, island disease, island fever, Japanese river fever, kedani fever, mite typhus, scrub typhus, shimamushi disease, tropic typhus, tsutsugamushi fever tsutsugamushi disease (tso͞o′tso͞o-gə-mo͞o [medical-dictionary.thefreedictionary.com]

  Fever clearance time. Median fever clearance 80 hours (Chiang Rai); 30 hours (Maesot). [doi.org]

  The clinical syndrome classically consists of a fever, rash, and eschar, but scrub typhus also commonly presents as an undifferentiated fever that requires laboratory confirmation of the diagnosis, usually by indirect fluorescent antibody (IFA) assay. [ncbi.nlm.nih.gov]

  At onset of fever, an eschar often develops at the site of the chigger bite. [msdmanuals.com]

• Lymphadenopathy

  Symptoms are fever, a primary lesion, a macular rash, and lymphadenopathy. Scrub typhus is related to rickettsial diseases. [msdmanuals.com]

  All five children had fever, vomiting and generalized lymphadenopathy, but none had eschar or rash. One was cured with doxycycline, remaining four patients treated with azithromycin and one died despite treatment. [ncbi.nlm.nih.gov]

  It presents with fever, headache, a macular rash, lymphadenopathy and eschar at the region of the mite bite. Tsutsugamushi disease is transmitted through a mite bite. [symptoma.com]

  Other finding werecardiomegaly (10 patients), pleural effusion (6 patients), mediastinal lymphadenopathy(3 patients). [synapse.koreamed.org]

  Tsutsugamushi disease: A mite-borne infectious disease caused by a microorganism, Rickettsia tsutsugamushi, characteristically with fever, headache, a raised (macular) rash, swollen glands (lymphadenopathy) and a dark crusted ulcer (called an eschar or [medicinenet.com]

• High Fever

  Tsutsugamushi disease is characterized by the early appearance of a black crust at the bitten area and the subsequent development of macular or macropapular rush on the whole body with high fever. [ncbi.nlm.nih.gov]

  It features headache, high fever and a rash. [medical-dictionary.thefreedictionary.com]

  Abstract A 47-year-old male was referred to our hospital with persistent high fever. [jstage.jst.go.jp]

• Chills

  After an incubation period of 6 to 21 days (mean 10 to 12 days), symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy. [msdmanuals.com]

  People with scrub typhus have a fever, chills, and a headache, followed by a rash several days later. To diagnose the infection, doctors test a sample of the rash and sometimes do blood tests. Scrub typhus is treated with an antibiotic. [merckmanuals.com]

  Case report of a 60-year-old woman who complained of fever, chills, headache, lymphadenopathy, and blurred vision in the right eye following an insect bite to the lower right forehead. [ncbi.nlm.nih.gov]

• Malaise

  As the eschar heals, there is a sudden onset of headache, malaise, anorexia, weakness, and fever, followed by pneumonia, a macular rash (on the trunk before the limbs), lymphadenopathy, hepato-splenomegaly, and conjunctivitis. [histopathology-india.net]

  Signs and symptoms include sudden headache, generalized muscle pain, malaise, and macular skin lesions. The infection may affect the central nervous system causing encephalitis. [fpnotebook.com]

  She also complained of malaise, loss of appetite, and dyspnea. Central nervous system symptoms such as headache and confusion were not observed. [tandfonline.com]

  Increasing malaise and confusion led to hospitalization; at presentation, she was febrile (body temperature, 40.0°C) and apathetic. [dx.doi.org]

• Cough

  Other symptoms associated with tsutsugamushi disease are lymphadenopathy, regional or generalized, ocular pain, a productive cough and infected conjunctiva. [symptoma.com]

  The second patient was a 30-year-old rice and corn farmer who presented with fever that had lasted for 10 days accompanied by cough, hearing loss, lymphadenopathy, and conjunctival suffusion. [doi.org]

  People may have a cough during the first week of fever. A rash appears about 5 to 8 days after the fever starts. [merckmanuals.com]

  Cough is present during the 1st week of fever, and pneumonitis may develop during the 2nd week. In severe cases, pulse rate increases; blood pressure drops; and delirium, stupor, and muscular twitching develop. [msdmanuals.com]

• Pneumonia

  As the eschar heals, there is a sudden onset of headache, malaise, anorexia, weakness, and fever, followed by pneumonia, a macular rash (on the trunk before the limbs), lymphadenopathy, hepato-splenomegaly, and conjunctivitis. [histopathology-india.net]

  Treatment for suspected malignancy and Pneumocystis carinii pneumonia was commenced. [jstage.jst.go.jp]

  As the disease progresses, pneumonia, encephalitis, delirium and splenomegaly may be added to the clinical picture. [symptoma.com]

  Pneumonia is a well-documented complication of rickettsial diseases, but ARDS is rare (6 cases) [3, –7]. [academic.oup.com]

  Chlamydia Pneumoniae 184. Mycoplasma Pneumoniae and Atypical Pneumonia Section D. Mycoplasma Diseases 185. Genital Mycoplasmas: Mycoplasma genitalium, Mycoplasma hominis, and Ureaplasma Species Section E. [books-express.ro]

• Sore Throat

  Other signs and symptoms include: rash, lymphadenopathy, hepatosplenomegaly, cough, sore throat, abdominal pain, and central nervous system involvement. [kjim.org]

• Severe Clinical Course

  It is generally said that the clinical course of JSF is worse than that of TD despite antibiotic treatment. The precise mechanism underlying the more severe clinical course of JSF is not fully understood. [ncbi.nlm.nih.gov]

• Vomiting

  All five children had fever, vomiting and generalized lymphadenopathy, but none had eschar or rash. One was cured with doxycycline, remaining four patients treated with azithromycin and one died despite treatment. [ncbi.nlm.nih.gov]

  The most common gastrointestinal symptoms of scrub typhus patients included vomiting, nausea, diarrhea and hametamesis or melena. Gastrointestinal signs included hepatomegaly, jaundice and abdominal pain. [histopathology-india.net]

  The most frequent presenting complaints were fever (100%), headache (91.3%), nausea and vomiting (73.9%), altered sensorium and seizures. Cases of scrub typhus that presented with altered sensorium were 14 (60.8%). [amhsr.org]

• Nausea

  The most common gastrointestinal symptoms of scrub typhus patients included vomiting, nausea, diarrhea and hametamesis or melena. Gastrointestinal signs included hepatomegaly, jaundice and abdominal pain. [histopathology-india.net]

  Clinical description After a silent incubation period of 10 days or more, onset is sudden with constant high fever, headache, obtundation, cough, myalgia and nausea. [orpha.net]

  Most patients who developed nausea and/or vomiting after treatment had a history of nausea or vomiting prior to admission. [doi.org]

  The most frequent presenting complaints were fever (100%), headache (91.3%), nausea and vomiting (73.9%), altered sensorium and seizures. Cases of scrub typhus that presented with altered sensorium were 14 (60.8%). [amhsr.org]

• Abdominal Pain

  Gastrointestinal signs included hepatomegaly, jaundice and abdominal pain. Since multiple serotypes exist and cross-immunity is transient, recurrent infections are common. [histopathology-india.net]

  Haug Browse recently published Learning/CME Learning/CME View all learning/CME CME Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis Case 4-2019: An 18-Year-Old Man with Abdominal Pain and Hematochezia Bridging the Gap Challenge Yourself [nejm.org]

  An episode of transient abdominal pain accompanied by vaginal bleeding occurred on the third hospital day. [doi.org]

  Other signs and symptoms include: rash, lymphadenopathy, hepatosplenomegaly, cough, sore throat, abdominal pain, and central nervous system involvement. [kjim.org]

  Trichuris trichiura infection, abdominal pain, and colonoscopy. Diagnosis of Trichuris trichiura whipworm by colonoscopic extraction. Endoscopic prevalence of whipworm infestation in northern Italy. [julian-g.ro]

• Jaundice

  Gastrointestinal signs included hepatomegaly, jaundice and abdominal pain. Since multiple serotypes exist and cross-immunity is transient, recurrent infections are common. [histopathology-india.net]

  […] thrombocytopenia (6/68, 8.82%), lymphadenopathy (4/68, 5.88%), eschar formation (8/68, 11.76%), diabetic ketoacidosis (1/68, 1.47%), hepatosplenomegaly (1/68, 1.47%), acute appendicitis (5/68, 7.35%), diabetes mellitus (5/68, 7.35%), ARDS (2/68, 2.94%), and jaundice [ijpmonline.org]

  Clinical presentations of these infections vary widely, from acute flu-like syndrome, with or without signs of organ dysfunction, such as jaundice or renal insufficiency, to multiorgan dysfunction mimicking severe sepsis syndrome ( 10 ). [doi.org]

  Symptoms Number of patients (%) Fever =7 days 9 7-10 days 7 =2 weeks 7 Myalgia 19 (82.6) Jaundice 6 (26.0) Breathlessness 7 (30.4) Cough 8 (34.7) Headache 21 (91.3) Nausea/vomiting 17 (73.9) Seizures 6 (26.0) Clinical signs Altered sensorium 14 (60.8) [amhsr.org]

• Conjunctival Injection

  Patient 1 had bilateral conjunctival injection and subconjunctival hemorrhage; patients 2-4 had conjunctival injection and episcleral vessel dilation bilaterally. [ncbi.nlm.nih.gov]

  Headache is severe and common, as is conjunctival injection. A macular rash develops on the trunk during the 5th to 8th day of fever, often extending to the arms and legs. It may disappear rapidly or become maculopapular and intensely colored. [msdmanuals.com]

  Case presentation: We report the case of a 4-year-old boy who presented with fever of 7 days duration and skin rash and bilateral conjunctival injection. He had a history of visiting a rural area with his grandmother. [circ.ahajournals.org]

• Myalgia

  In comparison to Lao patients, Japanese patients had a substantially lower prevalence of myalgia and hepatomegaly. [doi.org]

  Fever was the most common symptom in our group of patients which is similar to a previous report.[20] Narvencar et al.[2] in 2012 reported fever with myalgia as the predominant symptom in 80% of the patients, but in the present study, myalgia was observed [ijpmonline.org]

  Approximately at the tenth day following the initial infection, high fever, headaches, myalgia and fatigue emerge. The non-specificity of the symptoms constitutes a diagnostic obstacle at the early disease phase. [symptoma.com]

• Arthralgia

  He reported that his initial symptoms were high fever, chills, night sweats, intense headaches, myalgia, and arthralgia that had started 3 weeks earlier, but his fever and systemic symptoms had resolved spontaneously after 1 week. [dx.doi.org]

• Skin Rash

  An 85-year-old female farmer was admitted to our hospital for fever, general fatigue, and skin rash. Cephalosporin was not effective and minocycline was dramatically effective. An eschar was discovered on her inguinal region after the defervescence. [ncbi.nlm.nih.gov]

  However, because of the initial lack of response to ASPC, generalized skin rashes without an ordinary stick wound which had diminished before the hospitalization, and a history of working outdoors in a nearby mountain area, the possibility of new type [jstage.jst.go.jp]

  Scrub typhus is transmitted to humans by chiggers infected with Orientia tsutsugamushi that attach to the skin and suck tissue fluid, and it is characterized by eschar, fever, headache, and skin rash ( 1, 3 ). [doi.org]

  He had erythematous macular rash on her trunk. Examination of his skin revealed an eschar on penile base of right scrotum. [circ.ahajournals.org]

• Pruritic Rash

  Two weeks earlier, she had noticed a transient pruritic rash on her abdomen, which had appeared after she had been collecting firewood in a local forest clearing. [dx.doi.org]

• Erythema

  The erythema develops on the torso, may gradually assume papular characteristics and may not be observed due to its transient nature. As the disease progresses, pneumonia, encephalitis, delirium and splenomegaly may be added to the clinical picture. [symptoma.com]

  Various sizes of edematous skin erythema were seen mainly at the trunk of the body (Figure 1A). Hepatosplenomegaly and lymphadenopathy were not apparent. [ncbi.nlm.nih.gov]

  The development of erythema migrans often coincides with other Lyme disease symptoms such as. When I try to deceive I myself have more nervous tics than a Lyme disease research facility. [tr-ex.me]

• Skin Eschar

  Pat = patient's skin eschar; Neg = negative control; Shi = Shimokoshi strain (positive control); Kt = Kato strain; M = marker (100 bp ladder). [ncbi.nlm.nih.gov]

• Headache

  After an incubation period of 6 to 21 days (mean 10 to 12 days), symptoms of scrub typhus start suddenly and include fever, chills, headache, and generalized lymphadenopathy. [msdmanuals.com]

  It presents with fever, headache, a macular rash, lymphadenopathy and eschar at the region of the mite bite. Tsutsugamushi disease is transmitted through a mite bite. [symptoma.com]

  Tsutsugamushi disease: A mite-borne infectious disease caused by a microorganism, Rickettsia tsutsugamushi, characteristically with fever, headache, a raised (macular) rash, swollen glands (lymphadenopathy) and a dark crusted ulcer (called an eschar or [medicinenet.com]

  People with scrub typhus have a fever, chills, and a headache, followed by a rash several days later. To diagnose the infection, doctors test a sample of the rash and sometimes do blood tests. Scrub typhus is treated with an antibiotic. [merckmanuals.com]

  Case report of a 60-year-old woman who complained of fever, chills, headache, lymphadenopathy, and blurred vision in the right eye following an insect bite to the lower right forehead. [ncbi.nlm.nih.gov]

• Confusion

  Scrub typhus serologic testing with the indirect immunofluorescence method as a diagnostic gold standard: a lack of consensus leads to a lot of confusion. Clin Infect Dis. 2007 ;44: 391 – 401. [Google Scholar] ]. [tandfonline.com]

  Scrub typhus serologic testing with the indirect immunofluorescence method as a diagnostic gold standard: a lack of consensus leads to a lot of confusion. Clin. Infect. Dis. 44 : 391 -401. ↵ Botelho-Nevers, E., and D. Raoult. 2007. [doi.org]

  Increasing malaise and confusion led to hospitalization; at presentation, she was febrile (body temperature, 40.0°C) and apathetic. [dx.doi.org]

• Stupor

  In severe cases, pulse rate increases; blood pressure drops; and delirium, stupor, and muscular twitching develop. Splenomegaly may be present, and interstitial myocarditis is more common than in other rickettsial diseases. [msdmanuals.com]

  […] are associated with all three types of typhus, such as: headache fever chills rash Symptoms of epidemic typhus usually appear suddenly and include: severe headache high fever (above 102.2°F) rash that begins on the back or chest and spreads confusion stupor [healthline.com]

  Patients above 18 years of age who exhibited altered mental states such as confusion, obtundation, stupor or coma without evident cause such as shock or hypoglycemia or presence of both headache and neck stiffness, or cerebrospinal fluid (CSF) counts [amhsr.org]

The complete workup for scrub typhus encompasses a multitude of tests and procedures, including routine blood tests, serology, and PCR.

More specifically, laboratory blood tests including a complete blood count and biochemical studies usually yield the following results:

• Lymphopenia, early in the course of the disease
• Lymphocytosis, during the progressed stage
• Decreased CD4:CD8 ratio
• Thrombocytopenia [7]
• Augmented SGOT/SGPT levels in up to 95% of the patients
• Hypoalbuminemia, in 50% of the patients

The aforementioned findings may also suggest a potential dengue fever or leptospirosis infection; the latter is known to often coexist with scrub fever [8].

Serologic tests are further carried out, as they constitute the primary diagnostic procedures. A direct immunoperoxidase test and an immunofluorescent assay are used to establish the diagnosis and are expected to yield a result displaying a 4-fold augmentation of antibody titers between acute and convalescent serum specimens [9]. All potential O. tsutsugamushi subtypes should be considered as a possibility and should, therefore, be separately investigated serologically. A dot immunoassay can also be employed in order to diagnose tsutsugamushi disease, whereas the immunochromatographic test, aimed at the detection of immunoglobulin (Ig) M and IgG antibodies exhibit a considerably greater sensitivity for an early diagnosis when compared to the standard immunofluorescence assay.

The polymerase chain reaction tests (PCR) has proven a valuable diagnostic tool, on eschar samples, early in the course of the disease. In third world countries, the method of choice is the Weil-Felix OX-K strain agglutination reaction; when more advanced medical facilities are available, this test is not opted for due to its decreased sensitivity.

• Leukopenia

  Leukopenia and abnormal liver function tests are commonly seen in the early phase of the illness. Pneumonitis, encephalitis, and myocarditis occur in the late phase of illness. [en.wikipedia.org]

• Rickettsia Orientalis

  Tsutsugamushi, which is caused by Rickettsia nipponica (Rickettsia orientalis, Rickettsia tsutsugamushi), is widely distributed over an area which includes Japan, Malaya, French Indo-China, Sumatra, the Philippines, other islands of the Pacific and northern [jamanetwork.com]

  The cross-protection test with mice for identification and differentiation of several strains of Rickettsia orientalis newly isolated in Japan. Jpn J Med Sci Biol 1959;12:391–404. [synapse.koreamed.org]

  Strain variation of Rickettsia orientalis in the complement fixation test. Jpn J Med Sci Biol. 1964;17:59–72. View Article PubMed Google Scholar Nakayama K, Yamashita A, Kurokawa K, Morimoto T, Ogawa M, Fukuhara M. [bmcinfectdis.biomedcentral.com]

The clinical response to doxycycline treatment in patients with early, mild scrub typhus in northern Thailand was compared with the results of treatment in Mae Sod, western Thailand. [ncbi.nlm.nih.gov]

No treatment failure was reported. No trials reported deaths or serious complications. There are several trials of scrub typhus treatment with antibiotics. [doi.org]

2: Antibiotic Treatment for Scrub Typhus in Pregnant Women. [antimicrobe.org]

Prognosis The disease course may be severe. However, the mortality rate depends on the geographic areas and varies from 3% in Taiwan up to 30% in Northern Japan. [orpha.net]

Prognosis Prognosis varies and depends on the severity of illness, which relates to the different strains of O tsutsugamushi, as well as to host factors. Severe disease is uncommon with antimicrobial treatment. [emedicine.com]

Etiology and Epidemiology The etiologic agent of scrub typhus, Rickettsia tsutsugamushi, is a natural infection of several trombiculid mites, most commonly L. deliensis. [cambridge.org]

The present research throws light on specific etiological agents that may cause AES and have found scrub typhus to be an important etiology. [doi.org]

To retrospectively confirm the suspected rickettsial disease (Scrub typhus) using a gold standard diagnostic test i.e. microimmunofluorescence in pediatric patients with acute febrile illness of unknown etiology. [ncbi.nlm.nih.gov]

A number of microorganisms were hypothesized as an etiology of the illness. This is the first reported case of Kawasaki disease with tsutsugamushi disease. [circ.ahajournals.org]

The current system for Tsutsugamushi disease surveillance is useful for describing epidemiologic patterns by time, prefecture, and demographic characteristics. [ncbi.nlm.nih.gov]

Commission on Immunization of the Army Epidemiological Board, Washington, D. C. [jci.org]

Etiology and Epidemiology The etiologic agent of scrub typhus, Rickettsia tsutsugamushi, is a natural infection of several trombiculid mites, most commonly L. deliensis. [cambridge.org]

Short Communication Comparative Research on Epidemiological Aspects of Tsutsugamushi Disease (Scrub Typhus) between Korea and Japan Hyeong-Ae Bang, Myeong-Jin Lee 1 and Won-Chang Lee 2 * Faculty of Public Health, The Korean Public Health Association; [web.archive.org]

The infection and activation of endothelial cells contribute to the pathophysiology of scrub typhus as reported in rickettsioses. [onlinelibrary.wiley.com]

Scrub typhus: pathophysiology, clinical manifestations and prognosis. Asian Pac J Trop Med. 2012;5:261–264. [PubMed] [Google Scholar] 4. Botelho-Nevers E, Raoult D. Fever of unknown origin due to rickettsioses. [ncbi.nlm.nih.gov]

Scrub typhus: pathophysiology, clinical manifestations and prognosis. Asian Pac J Trop Med. 2012 Apr. 5(4):261-4. [Medline]. Watt G, Jongsakul K, Chouriyagune C, Paris R. [emedicine.com]

The net benefit should increase if the tsutsugamushi disease prevention program is continued and the implementation period is expanded to 10 years. [ncbi.nlm.nih.gov]

This study shows the status of scrub typhus in Japan in 1998 and provides important information for diagnosis and prevention. © The American Society of Tropical Medicine and Hygiene Article metrics loading... [doi.org]

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3. Berman SJ, Kundim WD. Scrub Typhus in South Vietnam: A Study of 87 Cases. Annals Internal Med. July 1973. 79:26-30.
4. Ogawa M, Hagiwara T, Kishimoto T, Shiga S, Yoshida Y, Furuya Y. Scrub typhus in Japan: epidemiology and clinical features of cases reported in 1998. Am J Trop Med Hyg. 2002 Aug. 67(2):162-5
5. Chanta C, Chanta S. Clinical study of 20 children with scrub typhus at Chiang Rai Regional Hospital. J Med Assoc Thai. 2005 Dec. 88(12):1867-72.
6. Sirisanthana V, Puthanakit T, Sirisanthana T. Epidemiologic, clinical and laboratory features of scrub typhus in thirty Thai children. Pediatr Infect Dis J. 2003 Apr. 22(4):341-5.
7. Edwards MS, Feigen RD. Rickettsial and Erlichial Diseases. Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Elsevier Saunders; 2009. Vol 2: 2677-2678.
8. Phimda K, Hoontrakul S, Suttinont C, Chareonwat S, Losuwanaluk K, Chueasuwanchai S. Doxycycline versus azithromycin for treatment of leptospirosis and scrub typhus. Antimicrob Agents Chemother. 2007 Sep. 51(9):3259-63.
9. Phetsouvanh R, Blacksell SD, Jenjaroen K, Day NP, Newton PN. Comparison of indirect immunofluorescence assays for diagnosis of scrub typhus and murine typhus using venous blood and finger prick filter paper blood spots.