ricketssial fevers , particularly scrub typhus are some of the important reemerging diseases of present days . indica is a disease of the spotted fever bio - group of rickettsia , spread by the bite of an infected tick . there had been a few reports of itt from pune district of maharashtra , himachal pradesh , in a french traveller returning from india and in haryana . itt clinically differs from other spotted fever group ( sfg ) in that maculopapular rash often turns purpuric , absence of inoculation eschar ( eschar if present , is always single ) , and absence of lymphadenopathy . recently , there are few published reports of occurrence of gangrene of the extremities in case of itt , which is an uncommon complication in cases of spotted fever rickettsiosis . along with gangrene , these cases had severe manifestations of sepsis and multiorgan dysfunction syndrome such as acute kidney injury , liver dysfunction , delirium , and seizure . hereby , we present a life - threatening case of itt presenting with atypical skin manifestations in the form of purpura fulminans ( retiform purpura all over the body ) , bullous eruptions and multiorgan failure . the weil - felix ( w - f ) test was very helpful in confirming the diagnosis . a 45-year - old male patient from nanded , maharashtra , was admitted to our intensive care unit ( icu ) with fever of 1 week , cough , generalized weakness , loose motions , and altered sensorium of 2 days duration with a presumptive diagnosis of viral encephalitis as he had a brief history of herpetiform rash on the back prior to fever . the rash had become more generalized with a few petechiae and one ecchymotic patch . on examination , he was disoriented , irritable , not obeying verbal commands , but moving all limbs . routine laboratory investigations revealed severe thrombocytopenia ( 30,000/cumm ) , raised urea ( 89 mg / dl ) and creatinine ( 3 mg / dl ) , raised liver enzymes with increased serum bilirubin ( total bilirubin 9.1 mg / dl , direct 6.7 mg / dl , increased lactate and ammonia , normal coagulation parameters , including fibrinogen . arterial blood gas analysis revealed severe metabolic acidosis , which improved with fluid resuscitation and the urine output improved . patient was started on broad spectrum antibiotics [ i.v meropenem and ciprofloxacin ] in view of sepsis and multiorgan dysfunction . he was intubated and connected to mechanical ventilator support as he developed neurologic , hemodynamic and respiratory deterioration . a magnetic resonance imaging brain was normal . a generalized retiform purpuric rash ( purpura fulminans ) was noted all over the body along with high grade fever and hypotension [ figure 1 ] . blood was negative for malaria parasite ; dengue and leptospira serology were negative ( dengue immunoglobulin m [ igm ] capture enzyme - linked immunosorbent assay [ elisa ] , panbio pty . , ltd . , gram stains of the skin biopsy failed to reveal intracellular / extracellular gram - negative diplococci and serum / urine neisseria meningitidis ag detection were negative ( bd directigen meningitis combo test , becton dickinson , usa ) . venereal disease research laboratory , carbogen , rapid plasma reagin card test ( tulip diagnostics pvt . , ltd . , india ) , acute hepatitis profile ( igm hepatitis a virus , igm hepatitis e virus , hepatitis b surface antigen , igm antihepatitis b core ) , hepatitis c virus antibodies were negative ( by chemiluminescent immunoassays [ abbott architect , ( abbott laboratories , abbott park , il , usa ) ] ) vasculitis workup ( antinuclear antibody profile , perinuclear antineutrophil cytoplasmic antibody , cytoplasmic antineutrophil cytoplasmic antibody , cryoglobulin , compliment c3 and c4 ) did n't reveal any abnormality ( euroimmun , lbeck , germany ) . a set of three blood cultures was drawn before starting antimicrobials and urine culture were sterile . w - f test revealed significant titer ( ox-2 [ 1:320 ] , ox-19 [ 1:40 ] ox - k [ 1:40 ] [ progen , tulip diagnostics , goa , india ] serology to orientia tsutsugamushi [ scrub typhus ] was negative [ sd tsutsugamushi , bioline ] ) the patient was immediately started on doxycycline . skin biopsy revealed mildly hyperkeratotic and flattened epidermis , widespread separation of the epidermis , and dermis [ figure 3 ] . direct immunofluorescence study was negative for immunoglobulin a , immunoglobulin g , igm and c3c in the epidermis and dermis . toxic epidermal necrosis , fixed drug eruption ( drug hypersensitivity ) and graft versus host disease were less likely due to the presence of prominent vasculitis . purpuric rash in the lower limbs ; note soles are not involved bullous eruptions over the hemorrhagic rash mildly hyperkeratotic and flattened epidermis , widespread separation of the epidermis and dermis as the patient improved neurologically and hemodynamically , after 48 h of doxycycline therapy , he was extubated and shifted out of icu . the serum creatinine improved from 3 to 1 mg / dl , though the liver enzymes were still elevated , serum bilirubin decreased from 9.1 to 2.5 mg / dl . the retiform rash started to fade and patient improved , clinically [ figure 4 ] . indica is a disease of the spotted fever biogroup of rickettsia , spread by the bite of an infected tick . the disease is characterized by sudden onset of moderate to high grade fever , malaise , deep muscle pain , headache , and conjunctival suffusion . rash is usually maculopapular to start with , begins on the 3 day of fever in the extremities , moves centripetally and involves rest of the body . itt also differs from mediterranean spotted fever , the disease caused by the type strain of r. conorii , in that the rash is often purpuric and an inoculation eschar at the bite site is seldom identified . between 1996 and 1998 , serological testing amongst residents of south india , who presented with pyrexia of unknown origin confirmed that spotted fever rickettsosis continues to occur in south india . all the documented cases so far have been diagnosed by the geographic prevalence of rickettsial species , clinical features , nonspecific serologic tools , such as the w - f test and response to treatment . the only documented case of infection diagnosed by strain weil - felix test , based on detection of antibodies to various proteus antigens with cross reacting epitopes to antigens of genus rickettsiae ( except rickettsia akari ) has low sensitivity and specificity for diagnosis of these infections , has been evaluated to be useful in developing countries as first diagnostic step in diagnosis of rickettsial diseases . either a four - fold rise in agglutinin titer in paired sera or single titer of more than equal to 1:320 is considered diagnostic for infection with these febrile agents . whole cells of proteus vulgaris ox-2 react strongly with sera from persons infected with sfg rickettsiae except rocky mountain spotted fever ( rmsf ) and whole cells of p. vulgaris ox-19 react with sera from persons infected with typhus group rickettsiae as well as with rmsf . one of the major limitations of w - f test is the cross - reactivity among several rickettsial species . specific investigations like immunoflourescence , western blot or polymerase chain reaction based tests , which are helpful in making an accurate diagnosis of rickettsial diseases are expensive and not readily available . our patient , a villager , had no occupational history but belonged to maharashtra , where tick borne rickettsiosis is prevalent . he had pneumonitis , thrombocytopenia and deranged liver function tests , which is not typical of itt . the reticulate ecchymotic patches sparing palms , sole along with hypotension , shock , requiring ionotropic support , altered level of consciousness led to an initial suspicion of meningococcemia . subsequently , bullous eruptions appeared on the hemorrhagic rash which is not the usual presentation of itt . the w - f test ( ox-2 titer , 1 ; 320 ) was very helpful in coming to a diagnosis .
seriously ill patients presenting with purpura fulminans , sepsis and multi - organ failure often require extensive diagnostic workup for proper diagnosis and management . 
 host of common infections prevalent in the tropics , e.g. malaria , dengue ; other septicemic infections e.g. meningococcemia , typhoid , leptospirosis , toxic shock syndrome , scarlet fever , viral exanthems like measles , infectious mononucleosis , collagen vascular diseases ( kawasaki disease , other vasculitis ) diseases , and adverse drug reactions are often kept in mind , and the index of suspicion for rickettsial illness is quite low . 
 we present a case of indian tick typhus presenting with purpura fulminans ( retiform purpura all over the body ) , sepsis and multiorgan failure without lymphadenopathy and eschar , successfully treated with doxycycline and discharged home . 
 hence , a high index clinical suspicion and prompt administration of a simple therapy has led to successful recovery of the patient .