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Scrub typhus, which is caused by  Orientia tsutsugamushi , is a public health problem in the Asian-Pacific region and is the third most frequently reported infectious disease in South Korea. While ultrastructural studies have been performed on  O .  tsutsugamushi  in murine fibroblasts, its variable locations in patients have hampered similar studies in humans. Two patients with scrub typhus agreed to provide an eschar biopsy and peripheral blood, respectively. Transmission electron microscopy was performed separately on the necrotic crust and perifocal skin of the eschar, the peripheral blood, and the infected murine L cells.  O .  tsutsugamushi  was located within or adjacent to the outermost layer of the perifocal inflamed skin of the eschar but not in the necrotic centre.  O .  tsutsugamushi  in peripheral blood monocytes exhibited the characteristic features of  O .  tsutsugamushi  in L cells, namely, nearly round shaped bacteria with a size of 1–2 µm and a double membrane bearing a clear halo-like outer layer. The findings confirmed that the bacterium was predominantly located in the inflamed skin around the eschar and that the bacterium had the same ultrastructural features in human monocytes as in L cells. These findings suggest that the perifocal area, not the necrotic centre, should be sampled for diagnosis.

Ultrastructural visualization of Orientia tsutsugamushi in biopsied eschars and monocytes from scrub typhus patients in South Korea