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Dear Editor, Scrub typhus, a rickettsial illness caused by Orientia tsutsugamushi, is transmitted by the bite of the larval form (chigger) of the trombiculid mite. Scrub typhus is prevalent in the ‘tsutsugamushi triangle,’ which stretches from Pakistan and Afghanistan in the western to northern parts of Australia in the southern to northern Japan in the north, although there are reports from other regions.1 The typical presentation is a short febrile illness associated with a pathognomonic cutaneous ‘cigarette burn’ eschar, but neuropsychological features are increasingly being described.2 Commonly, these include seizures and aseptic meningitis. Rarer neurological syndromes include extrapyramidal features, hearing loss, and opsoclonus.2 We present a patient with opsoclonus-myoclonus syndrome (OMS) as an initial manifestation of scrub typhus. A 23-year-old pregnant female, in the 36th week of gestation, presented to the emergency room with high-grade fever for one week along with abnormal movements of her eyes and limbs from day two of fever onset. There was no history of drug or toxin intake. She had been well otherwise and had no significant past medical history. On examination, she was restless and appeared sick. Her blood pressure was 90/50 mm Hg, pulse rate 120 beats/minute, respiratory rate 32 breaths/minute and oxygen saturation 96% on room air. She had bilateral basal crepitations. She was also noted to have a typical ‘cigarette burn’ eschar of scrub typhus in the left submammary region (Figure 1). On neurological examination, she was conscious and oriented to time, place and person. She was observed to have conjugate, chaotic, multidirectional eye movements consistent with opsoclonus, as well as myoclonic jerks involving all four limbs (Supplementary Video 1 in the online-only Data Supplement). Motor examination revealed normal tone, power and deep tendon reflexes. There were no features of parkinsonism, such as bradykinesia or rigidity. There were no features of cerebellar dysfunction, and she was able to perform the finger-nose test, the heel-knee-shin test and the tandem gait test normally. Laboratory evaluation showed elevated leukocyte count (13,000 cells/mm3), thrombocytopenia (platelet count 90,000 cells/mm3), deranged renal function (blood urea nitrogen = 64 mg/dL, serum creatinine = 1.4 mg/dL) and deranged hepatic function (elevated total bilirubin = 2.0 mg/dL, aspartate amino transferase = 11 IU/L, alanine transaminase = 121 IU/L), suggestive of multiorgan dysfunction. Serum electrolyte levels, including sodium (138 mEq/L), potassium (3.8 mEq/L), magnesium (2.1 mg/dL) and calcium (9.8 mg/dL), were normal. She underwent emergency cesarean section followed by intensive care admission. She was treated with injectable azithromycin for a period of 10 days, along with supportive management. The diagnosis of scrub typhus was confirmed by IgM ELISA. Vasculitis markers (anti-nuclear antigen, rheumatoid factor, anti-neutrophilic cytoplasmic antibodies) were negative. A detailed serum autoimmune (antibodies to NMDA receptor, LGI1, CASPR2, AMPA receptor, GluR1/GluR2, GABA-B, GAD, anti-thyroid peroxidase) and paraneoplastic antibody profile (anti-Hu, anti-Yo, anti-Ri, anti-CV2, anti-Ma2, anti-amphiphysin) was nonrevela-

Opsoclonus-Myoclonus Syndrome as a Heralding Feature of Scrub Typhus: An Illustrative Case with a Video Vignette