Cerebellitis as an atypical manifestation of scrub typhus

A 21-year-old-man presented in a semiconscious state with 2 days' inability to walk and 5 days' history of fever (102.2°F) and rash. Examination revealed severe ataxia, slurred speech, and a scrotal scar (figure 1). Head CT and CSF studies were normal. Brain MRI revealed diffuse cerebellar cortical hyperintensity on T2 and fluid-attenuated inversion recovery images (figure 2, A and B), with restriction (figure 2C) and postcontrast enhancement (figure 2D) suggesting inflammation. Weil-Felix test (OX-K-1:320)1 and immunoglobulin M ELISA were positive for scrub typhus. Improvement occurred after oral doxycycline.