Scrub Typhus Meningoencephalitis With Concurrent Brucellosis in Rural Nepal: Diagnostic Challenges With Negative PCR in a Low-Resource Setting.

Scrub typhus is an important cause of acute febrile illness in Nepal and can rarely present with meningoencephalitis and multiorgan involvement. We report a 32-year-old female farmer from rural Nepal who presented during the monsoon season with high-grade fever, myalgia, vomiting, and an eschar following an unidentified forest bite. She developed meningismus, hypotension, mild acute respiratory distress syndrome, and transaminitis. Cerebrospinal fluid showed lymphocytic pleocytosis and elevated protein, while bacterial culture, acid-fast staining, and GeneXpert were negative. Serum scrub typhus IgM was positive, whereas Brucella abortus IgM was borderline positive. CSF PCR for both pathogens was negative. Based on the characteristic eschar, clinical presentation, CSF findings, epidemiological exposure, and exclusion of alternative diagnoses, scrub typhus meningoencephalitis was considered the most likely diagnosis. She improved with doxycycline-based therapy and achieved complete neurological recovery. This case highlights the challenges of diagnosing scrub typhus in resource-limited settings despite negative PCR.