Intended for healthcare professionals

Endgames Case Review

Skin lesion in a critically ill man

BMJ 2015; 351 doi: (Published 28 August 2015) Cite this as: BMJ 2015;351:h4570
  1. Ming-Hua Zheng, consultant hepatologist1,
  2. Ke-Qing Shi, core medical trainee1,
  3. Yong-Ping Chen, consultant hepatologist1
  1. 1Department of Infection and Liver Diseases, Liver Research Centre, First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
  1. Correspondence to: M-H Zheng zhengmh{at}

A 45 year old man was referred to the emergency department with a seven day history of high fever and chills. His condition suddenly deteriorated and he presented with dark yellow urine of decreased volume, tachypnoea, and drowsiness. His medical history included hypertension, type 2 diabetes, and heavy consumption of alcohol (>6.8 units, or >50 g alcohol/day for 12 years). He had travelled to a mountainous region in Fujian province of China 12 days earlier.

On admission to intensive care, he was found to have a round ulcer near the navel, 3 mm in diameter, with marginal swelling and peripheral blushing (fig 1). The rest of his physical examination, including the cranial nerve, was normal. Table 1 shows the results of his blood tests. No obvious abnormality was visible on routine computed tomography of the brain and lung; however, hepatomegaly and a slight splenomegaly were seen on a computed tomogram of his abdomen.

View this table:
Table 1

The patient’s laboratory test results in the intensive care unit

Fig 1 Skin lesion in the abdomen


  • 1. What is the differential diagnosis?

  • 2. What further tests are needed?

  • 3. Given the most likely diagnosis how should the condition be treated?

  • 4. What risk factors affect prognosis?

  • 5. How can primary care practitioners make a straightforward diagnosis?


1. What is the differential diagnosis?

Short answer

Tsutsugamushi disease (severe type), typhoid fever, relapsing fever, and epidemic haemorrhagic fever.


The final diagnosis was tsutsugamushi disease (severe type), a rickettsial disease, which is an acute lethal infectious disease caused by Orientia tsutsugamushi. The micro-organism is introduced through the skin by the bite of a larval stage trombiculid mite. It occurs in people who visit mite infected habitats such as brush and grass. It is an emerging and re-emerging condition in many Asian countries, including China, Japan, Korea, and other countries in east and South …

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