A three-generation family cluster with COVID-19 infection: should quarantine be prolonged?

OBJECTIVES: Families are a transmission route for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) because of the close contact. Monitoring of the viral load will be a valuable method to reduce the optimal number of quarantine days, especially in presymptomatic and symptomatic carriers of their households. The traditional three-generation families living together are seen frequently in East Asia, including in Taiwan. STUDY DESIGN: We report on a family cluster with six individuals infected with coronavirus disease in Taiwan. METHODS: The current public policy in Taiwan is quarantine for at least 14 days, based on the incubation period, or until the patient has tested negative three days in a row using the SARS-CoV-2 reverse transcription polymerase chain reaction. Details on the onset date of clinical symptoms, throat swab conversion, and course of disease were collected from medical records retrospectively. RESULTS: In the household of this three-generation Taiwanese family, the infection rate was 60%. The ratio of males to females was 4:2, and the age range was 11-85 years. The prevalence of asymptomatic disease was 33.3% (2/6). The longest throat swab conversion time was 37 days, and the estimated course of disease from symptoms to first conversion of throat swab was 59 days. CONCLUSIONS: Large families, including three-generation families in a single dwelling, should be monitored when the index case is found. Presymptomatic and symptomatic family members could be quarantined for an appropriate duration which, in our experience, is 2 months.

[Short-term outcomes of single incision plus one port laparoscopic surgery for colorectal cancer].

Objective: Although single port laparoscopic surgery has achieved good clinical results, many surgeons are discouraged by the difficulties of operation, conflict of instruments, lack of antagonistic traction, and straight-line perspective. Therefore, some surgeons have proposed a single incision plus one hole laparoscopic surgery (SILS+1) surgical method. This study explored the safety and feasibility of SILS+1 for radical resection of colorectal cancer. Methods: A descriptive cohort study was carried out. The clinical data, including the operation, pathology and recovery situation, of 178 patients with colorectal cancer undergoing SILS+1 at Department of General Surgery, Nanfang Hospital, Southern Medical University from March 2018 to January 2019 were prospectively collected and retrospectively analyzed. Clavien-Dindo criteria was used for postoperative complication evaluation and visual analog scale was used for pain standard. Follow-up studies were conducted through outpatient service or telephone and the follow-up period was up to May 2019. Results: A total of 178 patients with colorectal cancer underwent SILS+1, including 111 male patients (62.4%) with an average age of 59 years. Eleven (6.2%) patients received added 1-3 operation ports during operation, and 1 patient was converted to open surgery due to ileocolic artery hemorrhage. The operative time was (135.2±42.3) minutes. The intraoperative blood loss was (34.6±35.5) ml. The number of harvested lymph nodes was 33.1±17.6. The distal margin was (4.7±17.8) cm. The proximal margin was (10.2±5.3) cm. Operation-related complications were observed in 16 patients (9.0%) within 30 days after the operation, of whom 6 had Clavien-Dindo III complications (3.4%). The postoperative pain scores were lower than 3. The average postoperative hospital stay was (5.6±2.6) days. Three patients (1.7%) returned to hospital within 30 days after operation due to intestinal obstruction and infection around stoma. The cosmetic evaluation of all the patients was basically satisfied. Conclusion: SILS+1 is safe and feasible in the treatment of colorectal cancer, and can reduce the postoperative pain.

MiR-526b suppresses cell proliferation, cell invasion and epithelial-mesenchymal transition in breast cancer by targeting Twist1.

OBJECTIVE: The aberrant expression of microRNAs (miRNAs) acts as crucial regulators in the tumorigenesis of breast cancer (BC). The aim of the study is to investigate the functional effects of miR-526b expression in breast cancer progression. PATIENTS AND METHODS: The expression level of miR-526b in breast cancer tissues and cell lines was detected by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). Cell proliferation, migration, and invasion capacity was detected by CCK-8 cell proliferation, colony formation, and transwell invasion assays after up-regulating or down-regulating miR-526b expression in breast cancer cells. Bioinformatics analysis and Dual-Luciferase reporter gene assays were used to demonstrate that Twist1 was a target of miR-526b. Western blot analysis was also performed. RESULTS: We showed that miR-526b expression was significantly downregulated in breast cancer tissues compared to adjacent normal tissues. Lower miR-526b expression was associated with lymph node metastasis in breast cancer patients. Function assays showed that upregulation of miR-526b expression suppressed cell proliferation, cell colony formation, and cell invasion ability in breast cancer. Furthermore, the upregulation of miR-526b suppressed EMT makers Vimentin expression but increased the E-cadherin expression. Mechanically, we showed that miR-526b inhibited cell EMT process by targeting Twist1 expression. CONCLUSIONS: Thus, our evidence indicated that miR-526b may serve as a potential target of breast cancer treatment.

Long non-coding RNA H19 promotes the osteogenic differentiation of rat ectomesenchymal stem cells via Wnt/ß-catenin signaling pathway.

OBJECTIVE: To investigate the molecular mechanism of long noncoding RNA (lncRNA) H19 that promotes osteogenic differentiation in rat ectomesenchymal stem cells (EMSCs). MATERIALS AND METHODS: EMSCs were isolated from rat fetal facial processes by flow cytometry. Osteogenic markers CD29, CD90, CD44, CD57, Nestin and sox10 were detected by fluorescent immunoassay. ß-catenin and Wnt pathway target genes were detected by Real-time polymerase chain reaction (RT-PCR) and Western blot after the construction of transient interference H19, a stable expression of H19 EMSCs cell line and the induction of osteogenic differentiation of EMSCs cells. EMSCs of H19 overexpression were treated with Wnt/beta-catenin signaling pathway inhibitor Wnt-C59, and the expressions of beta-catenin and osteogenic markers were detected by RT-PCR and Western blot. Furthermore, the mechanism of H19 regulating Wnt/beta-catenin signaling pathway was explored by transfecting miR-22 and miR-141 mimics and luciferase reporter assays. RESULTS: EMSCs were successfully isolated and identified, osteogenic markers CD29, CD90, CD44, CD57, Nestin and sox10 were significantly overexpressed. Osteogenesis-induced solution significantly increased the expression of H19 and osteogenic markers ALP, Runx2, BMP and OCN in EMSCs (p<0.05). Interference with H19 significantly inhibited the expressions of osteogenic markers, beta-catenin and target genes of Wnt/beta-catenin signaling pathway (p<0.05), while upregulation of H19 significantly promoted the expressions of these markers and genes in EMSCs (p<0.05). Wnt-C59 inhibitors treatment inhibited the Wnt/beta-catenin signaling pathway and osteogenic differentiation in EMSCs with H19 overexpression (p<0.05). Furthermore, H19 could block the inhibitory effect of miR-22 and miR-141 on ß-catenin and activate the Wnt/beta-catenin signaling pathway after transfecting miR-22 mimics and miR-141 mimics in EMSCs (p<0.05). CONCLUSIONS: LncRNA H19 can promote the osteogenic differentiation of rat EMSCs by activating Wnt/beta-catenin signal, providing a theoretical basis for the application of EMSCs in tooth tissue engineering regeneration and repair.

All fiber-coupled, long-term stable timing distribution for free-electron lasers with few-femtosecond jitter.

We report recent progress made in a complete fiber-optic, high-precision, long-term stable timing distribution system for synchronization of next generation X-ray free-electron lasers. Timing jitter characterization of the master laser shows less than 170-as RMS integrated jitter for frequencies above 10 kHz, limited by the detection noise floor. Timing stabilization of a 3.5-km polarization-maintaining fiber link is successfully achieved with an RMS drift of 3.3 fs over 200 h of operation using all fiber-coupled elements. This all fiber-optic implementation will greatly reduce the complexity of optical alignment in timing distribution systems and improve the overall mechanical and timing stability of the system.

Randomized, double-blind, comparative study of levofloxacin and ofloxacin in the treatment of complicated urinary tract infections.

Levofloxacin, the optical S-(-) isomer of ofloxacin, was compared with ofloxacin in the treatment of complicated urinary tract infections (UTIs). Patients eligible for the trial were randomly assigned to either a daily 300 mg of levofloxacin or 600 mg of ofloxacin for 10 consecutive days. The double blind design was achieved by a double-dummy technique utilizing placebo of both test drugs. Efficacy variables measured were: urine white blood cell counts for the effects on pyuria, urine cultures for effects on bacteriuria, subjective symptoms, and overall clinical efficacy which combined results from effects on bacteriuria, pyuria and subjective symptoms. Safety endpoints were the incidence of adverse events and laboratory test monitoring after a 10-day treatment. A total of 104 patients were enrolled into this trial and 46 patients were evaluable for efficacy endpoints. Most patients with culture-negative (48 cases), mixed flora (5 cases), and less than 10,000 colony forming units/mL of bacteria (3 cases) were excluded from analyses. None of the demographic and baseline characteristics were significantly different between treatments (p > 0.05). Therapeutic effects upon bacteriuria for both treatment groups were similar with a response rate of 90.0% for levofloacin and 88.5% for ofloxacin. Efficacy on the subjective symptoms revealed response rates of 90.0% in the levofloxacin group and 80.7% in the ofloxacin group, with the overall clinical efficacy of 90% in the levofloxacin and 84.6% in the ofloxacin groups. All the efficacy variables measured between treatments were not statistically different which indicated an equivalent efficacy in the treatment of complicated UTIs (p > 0.05). Of the 104 patients exposed to the test medications, only three having adverse effects. One developed epigastralgia in the levofloxacin group, and 2 developed a headache in the ofloxacin treatment. All events were moderate in severity and were resolved quickly after medication. Four laboratory data abnormalities were observed (defined by 25% as exceeding the normal range), and were considered to not be related to the test medications. Both antibiotics were efficacious in the treatment of complicated UTIs (response rates ranging from 80 to 90%) and were well tolerated. Levofloxacin demonstrated comparable antibacterial effects and safety profiles with double potency dosage, compared to the ofloxacin.

Outcomes of Aeromonas bacteremia in patients with different types of underlying disease.

Over a 6-year period, 42 patients with different underlying diseases developed Aeromonas bacteremia in our hospital. The male to female ratio was 2:1. The vast majority of these patients had underlying diseases, including various types of neoplasm (n = 14), liver cirrhosis (n = 11), biliary tract disorder (n = 10) and other illnesses (n = 7). Community-acquired bacteremia was predominant (33 cases, 79%). Aeromonas hydrophila was the most common species isolated (88%). Monomicrobial bacteremia was more common than polymicrobial bacteremia (64% vs 36%). Monomicrobial bacteremia was associated with neoplasm or liver cirrhosis in 80% of patients. Polymicrobial bacteremia was more common in patients with biliary tract disorder than in patients from other groups (60% vs 40%). Escherichia coli (60%) was the predominant concomitant organism isolated. The major clinical manifestations were fever (74%), jaundice (57%), and abdominal pain (45%). Recognized infection sites included biliary tract, soft tissue involvement, peritoneal involvement, while 50% of patients had no recognized infection site. Eight patients (80%) received cholecystectomy due to gall stone with acute cholecystitis. However, none of the cirrhotic patients with necrotizing fasciitis received surgical treatment. The mortality attributed to Aeromonas bacteremia was 70%. Patients with liver cirrhosis or malignancy had a higher acute mortality (death within 7 days after admission) than the other patients (89% vs 11%). We conclude that Aeromonas bacteremia can cause a rapidly fatal outcome and should be considered an important pathogen for septicemia in patients with liver cirrhosis or neoplasm.

Efficacy of cefepime versus ceftazidime in the treatment of adult pneumonia.

Effective empiric treatment of pneumonia requires antibiotic coverage against gram-negative and gram-positive pathogens, including drug-resistant isolates. This study evaluated the efficacy of cefepime treatment in 20 patients with community-acquired pneumonia (CAP) and 21 patients with hospital-acquired pneumonia (HAP), and ceftazidime treatment in 20 patients with HAP. The mean age of patients was over 70 years. More than half of the patients had multiple lobe involvement. There was no significant difference in the severity of illness according to the acute physiology, age, chronic health evaluation (APACHE) III score between the HAP-cefepime and HAP-ceftazidime group. The most common bacteria isolated from sputum of patients with CAP were Streptococcus pneumoniae (n = 7), Klebsiella pneumoniae (n = 4), and Pseudomonas aeruginosa (n = 2). In patients with HAP, P. aeruginosa (n = 13), Acinetobacter baumannii (n = 11), Serratia marcescens (n = 6), K. pneumoniae (n = 5), Stenotrophomonas maltophilia (n = 5), Enterobacter cloacae (n = 3), Citrobacter spp. (n = 2), and Escherichia coli (n = 2) were isolated. The cure rates were 95%, 76%, and 60% in the CAP-cefepime group, the HAP-cefepime group, and the HAP-ceftazidime group, respectively. The increased rates of antimicrobial resistance commonly found among isolates causing CAP and HAP indicate that extended-spectrum antimicrobial agents, such as cefepime, would be more appropriate therapeutic agents.

Clinical spectrum of Pseudomonas putida infection.

The clinical and microbiologic characteristics of 55 cases of Pseudomonas putida infection in 53 patients in a medical center in Taiwan from April 1988 to March 1993 are reported. P. putida was cultured in the decreasing order of frequency from urine (24 isolates), sputum (12), blood (10), wound discharge (3), peritoneal fluid (3), cerebrospinal fluid (2) and umbilical swab (1). Of the adult patients, 23% (12/53) were considered to be contaminated or colonized with P. putida. Of the 41 patients with manifest disease. 17 (41%) had urinary tract infections, 10 (24%) had pneumonia, 8 (19%) had septicemia, 3 (7%) had wound infections, 2 (5%) had meningitis and 1 (2%) had peritonitis. Of these, 55% were nosocomial infections. The case fatality rate was 29% (12/41). There was no significant correlation between patient mortality and the type of disease caused by the bacterium. Results of in vitro susceptibility tests suggested that imipenem and ceftazidime were more effective than other antimicrobials. This study indicates that the clinical spectrum of diseases caused by P. putida is broader and the incidence of true infection is higher than previously expected, especially among hospitalized patients who undergo invasive procedures such as placement of intravascular devices, urinary catheterization and intubation.

Hepatic dysfunction in scrub typhus.

Scrub typhus is an acute febrile illness that generally causes non-specific symptoms and signs of which fever is the most common. It is one of the causes of "fevers of unknown origin" in the Asia-Pacific region. The relationship between hepatic dysfunction and scrub typhus has been given little attention in the literature. From 1982 to 1993, 47 patients diagnosed with scrub typhus at Tri-Service General Hospital, Taipei, were studied, with attention being given to hepatic dysfunction. The medical records of these patients were reviewed thoroughly. Hepatic dysfunction occurred in 77% (36/47) of patients. Among the liver function parameters, the percentage of abnormality was 74.5% for aspartate aminotransferase, 74.5% for alanine aminotransferase, 57.4% for alkaline phosphatase, 44.7% for lactate dehydrogenase and 44.7% for serum bilirubin. Six patients presented with a picture of true hepatitis similar to acute viral hepatitis. The results indicate that hepatocellular damage does occur in scrub typhus, and is perhaps, more common than previously realized. We recommend that the differential diagnosis of patients from high-risk groups and endemic areas who present with hepatitis-like symptoms should include examination for scrub typhus.

Gram-negative bacillary meningitis in adults.

To evaluate the clinical aspects of gram-negative bacillary meningitis (GNBM), we reviewed 41 adult patients with bacteriologically proven gram-negative bacillary meningitis, seen from 1985 to 1990. Thirty-two patients had post-neurosurgical GNBM and nine patients had spontaneous GNBM. Spontaneous GNBM appeared to have a sudden onset, a relatively fulminant course, and was caused most often by Escherichia coli. Post-neurosurgical GNBM, however, had a more insidious onset, a more protracted course, and was more often caused by nosocomial organisms which were resistant to multiple antibiotics. The overall mortality was 39%. Patients treated with combined aminoglycoside therapy had a lower mortality rate than those treated with intravenous aminoglycoside (17% vs 48%). The use of third-generation cephalosporins has made a significant therapeutic advance in the treatment of GNBM, with a lower mortality of 21%. We recommend treatment of GNBM with third-generation cephalosporins and aminoglycosides. If aminoglycosides are to be employed, it is suggested that they be administered both intravenously and directly into the central nervous system.

Acute renal failure associated with scrub typhus: report of a case.

We report on a 25-year-old man who had scrub typhus with the unusual complication of acute renal failure. The clinical features of fever, headache, high Weil-Felix OX-K agglutination and Rickettsia tsutsugamushi immunofluorescence titers confirmed the diagnosis of scrub typhus. Acute renal failure was proven by oliguria, urinary diagnostic indices and renal biopsy. The patient had a complete recovery after adequate medical treatment.

Removal of bromate and assimilable organic carbon from drinking water using granular activated carbon.

This study investigated the feasibility of using granular activated carbon (GAC) to remove bromate ion (BrO3-) and assimilable organic carbon (AOC) from drinking water through a rapid small-scale column test (RSSCT) method and a pilot-scale study. Results from RSSCT indicated that the GAC capacity for BrO3- removal was dependent on the GAC type, empty bed contact time (EBCT), and source water quality. The GAC with a high number of basic groups and higher pHpzc values showed an increased BrO3- removal capacity. BrO3- removal was improved by increasing EBCT. The high EBCT provides a greater opportunity for BrO3- to be adsorbed and reduced to Br- on the GAC surface. On the other hand, the presence of dissolved organic carbon (DOC) and anions, such as chloride, bromide, and sulfate, resulted in poor BrO3- reduction. In the GAC pilot plant, a GAC column preloaded for 12 months achieved a BrO3- and AOC removal range from 79-96% and 41-75%, respectively. The BrO3- amount removed was found to be proportional to the influent BrO3- concentration. However, the BrO3- removal rate apparently decreased with increasing operation time. In contrast, the AOC apparently increased during the long-term operation period. This may be a result of the contribution due to new GAC being gradually transformed into biological activated carbon (BAC), and the bacterial biomass adsorbed on GAC surface hindering BrO3- reduction by GAC either by blocking pores or adsorbing at the activated sites for BrO3- reduction.

Short course of linezolid treatment for vancomycin-resistant Enterococcus faecium meningitis.

Enterococci might be one of the meningitis pathogens, but meningitis is rarely caused by vancomycin-resistant enterococci. In this report, we present a 69-year-old man who had the underlying chronic obstructive pulmonary disease with long-term steroid treatment suffered from a meningitis episode after hospitalisation for the urinary tract infection. The cerebrospinal fluid culture of the patient grew Enterococcus faecium which was resistant to vancomycin. A vancomycin-resistant E. faecium was also isolated from the rectal swab of the patient. These two E. faecium isolates were found to harbour the vanA gene and to be identical by pulsed field gel electrophoresis typing. The patient was treated successfully with intravenous linezolid, 600 mg every 12 h for 2 weeks. This was the first case of meningitis caused by vancomycin-resistant E. faecium in Taiwan.

Differential viral loads of human papillomavirus 16 and 58 infections in the spectrum of cervical carcinogenesis.

Human papillomavirus (HPV) load was reported to be related to the severity of cervical neoplasia but with controversy. The viral load-disease severity relationship was showed in HPV 16, but no study was made in HPV 58, the second most prevalent HPV in cervical cancer in East Asia. We studied cervical HPV loads in HPV 16- and HPV 58-infected cases of normal, low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), and invasive cervical cancer (CC) by using quantitative polymerase chain reaction (Q-PCR) with type-specific primers in defined cell number. With the exception of HPV 16 infection in normal, viral loads varied greatly in each disease regardless of genotypes. The load of HPV 16 differed significantly among disease severities, with a dramatic increase from normal (1.14 +/- 2.25 copies/cell) to LSIL, HSIL, and CC (1599 +/- 2301, 7489 +/- 24,087 and 1878 +/- 2979 copies/cell, respectively) (P < 0.01). No significant difference was noted among different HPV 58 infections, with loads in normal, LSIL, HSIL, and CC of 503 +/- 641, 7951 +/- 27,557, 353 +/- 744, and 1139 +/- 2895 copies/cell, respectively. In comparison with HPV 16, HPV 58 subclinical infection confers a significant higher load (P < 0.01). Different HPV types behave differentially in the spectrum of cervical carcinogenesis. Unlike HPV 16, the infection load of HPV 58 does not correlate to the clinical severity. The wide variation of HPV loads among different HPV types and among squamous intraepithelial lesions and CC makes the viral load test unrealistic in differentiating different severities of cervical neoplasia.

Neurological complications of varicella: a report of two cases.

Varicella (chickenpox) is the primary infection of Varicella-Zoster virus, characterized by generalized vesicular eruption, fever and mild constitutional symptoms. Chiefly infecting children of 1 to 14 years of age, the disease has been almost neglected because of its inevitable and benign outcome. Adults are rarely infected with an incidence of less than 20%. These two cases are presented of normal adults with marked neurological complications 10 and 14 days, respectively, following typical skin eruption of varicella. The first case developed transverse myelitis and the second, an encephalomyelitis. Neurological complications are very rare post-varicella infection. Although prognosis is good and complete recovery is the rule, still some morbidity with neurological sequelae and mortality have been reported. The present cases had extensive neurological deficit, despite aggressive treatment, making a high index of suspicion for differential diagnosis in patients who present with encephalitis. Especially following the typical exanthema of varicella, this possibility is emphasized and the literature is reviewed.

Enterococcal bacteremia in a medical center.

BACKGROUND: The enterococci have become important nosocomial pathogens. They can cause multiple site infections and enterococcal bacteremia becomes more frequently associated with a high mortality rate. Previous studies of enterococcal bacteremia showed a variety of results. To establish the significance and importance of enterococci as nosocomial pathogens in this hospital, to characterize their clinical pictures and to search for the risk factors for mortality, this retrospective study was performed. METHODS: There were 208 cases of enterococcal bacteremia which occurred from 1988 to 1992. Twenty-seven cases had no medical charts, dismissing possibility of evaluation. Finally, 181 cases of enterococcal bacteremia were analysed. RESULTS: One hundred and eighteen episodes were nosocomial infections. Polymicrobial bacteremia occurred in 68.5% of the patients and the most common co-isolate was Pseudomonas aeruginosa. Those patients (78.5%) with underlying diseases and malignancies were the most common underlying problems. The portal of entry could be found in 69.6 percent of patients, with the gastrointestinal tract the most common sources. Antimicrobial susceptibility testing showed high gentamicin resistance rate (89.5%), and ampicillin still had about 80 percent sensitivity rate. The group who received specific antibiotic therapy for enterococcus showed lower mortality (36.4% versus 47.6%). Only one case had infective endocarditis. Forty-nine patients suffered from septic shock, the cause of 30 deaths. Totally 75 patients died during hospitalization. Besides sepsis, another major cause of death was their underlying diseases itself. CONCLUSIONS: Enterococci have no doubt become important nosocomial pathogens and enterococcal bacteremia were associated with high mortality, especially in elderly patients with underlying diseases such as malignancy or diabetes. When clinically dealing with sepsis from the gastrointestinal or biliary tract, especially when previous cephalosporins therapy showed no response, the possibility of enterococcal bacteremia should always be considered.

Septicemia caused by Vibrio parahemolyticus: a case report.

Vibrio parahemolyticus is a halophilic marine vibrio commonly associated with outbreaks of acute gastroenteritis which also sometimes causes serious wound infection. It is an uncommon cause of septicemia. A few reports suggest that patients with chronic liver disease and leukemia are more susceptible. A case of liver cirrhosis with septicemia caused by this organism is discussed. The patient's condition rapidly deteriorated, and he died 12 hours after admission.

Cutaneous manifestation of Kikuchi's disease: a case report.

A 22-year-old male was admitted with a 1-month history of chills, fever, multiple skin eruption and painless lymphadenopathy. He has later been confirmed by typical histopathological findings to be a case of Kikuchi's histiocytic necrotizing lymphadenitis. Extranodal involvement with skin manifestation in Kikuchi's disease has rarely been reported; herein this unusual case is described.

Unusual presentation of acute abdomen in scrub typhus: a report of two cases.

Two young soldiers presented with acute abdomens, then received surgical procedures under initial impression of acute cholecystitis and acute appendicitis respectively. Operative findings did not confirm the initial diagnosis, and the clinical condition did not improve after operation. Scrub typhus was suggested later by clinical manifestations of fever, chills, headache, lymphadenopathy, skin rash and presence of eschar formation; this diagnosis was finally confirmed by positive serologic results of high Weil-Felix OXK agglutination and/or Rickettsia tsutsugammushi immunoflorescence titers in paired sera. Both patients rapidly became afebrile after administration of tetracycline. This unusual presentation with acute abdomen in scrub typhus is emphasized, with caution that the possibility of scrub typhus should be taken considered, especially in patients coming from hyperendemic areas.