THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HELTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[05-09-2025 11:33] PPM 1: Please describe your patient's hourly routine over 24 hours when s/he was perfectly alright
Next please describe what happened to his/her hourly 24 hour routine once the disease took hold on his her life
Please mention specifically which part of the patient's hourly routine was disrupted
What are the patient's current requirements from us like if we had to give her him a single medicine which problem would they prefer it to address?
Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here:
[05-09-2025 11:52] PPM 3: I'll speak with aunty and I'll Write back sir.
also what is the need for an abdomen picture in this case of insect bite
[05-09-2025 12:11] PPM 1: For her other symptoms
And to assess her phenotype to assess her risk for metabolic syn
[05-09-2025 12:17] PPM 3: But her symptoms or of insect bite
[05-09-2025 13:14] PPM 4: I’m not a doctor, but I can help you think through the possible causes and next steps for evaluation and treatment of this lesion.
From the image, this lesion shows:
A small raised nodule with a central dark point (possible punctum).
Mild surrounding erythema (reddish hue).
Localized swelling.
If it's currently attributed to an insect bite, there are still several etiologic possibilities to consider:
1. Possible Etiologies
Simple insect bite reaction: Local allergic or inflammatory response.
Infected bite / cellulitis / abscess: If bacteria enter via the bite, infection can occur.
Retained insect parts or foreign body: Central dark spot may represent a retained stinger, tick, or necrotic tissue.
Furuncle (boil): If Staphylococcus aureus infection occurs in hair follicles.
Spider bite or arthropod envenomation: Some spiders cause necrosis at the site (e.g., Loxosceles species).
Other dermatologic conditions mimicking insect bites: Epidermoid cyst, early cutaneous leishmaniasis (especially in endemic areas), or myiasis (larval infestation).
---
2. Diagnostic Workup
History:
Onset, progression, associated pain, discharge, fever.
Travel history, exposure to insects, pets, or livestock.
Systemic symptoms (fatigue, lymphadenopathy).
Physical exam:
Check for warmth, tenderness, fluctuance (suggests abscess).
Examine for lymphangitis or enlarged lymph nodes.
Evaluate for necrotic center or ulceration.
Investigations (if indicated):
Swab for culture if discharge present.
Ultrasound to detect abscess or foreign body.
Biopsy or scraping if atypical lesions or slow healing (rule out leishmaniasis, atypical infections).
---
3. Therapeutic Options
Initial measures:
Clean with soap and water.
Topical antiseptic (e.g., povidone-iodine).
Cold compresses for swelling.
Oral antihistamines if itching prominent.
If infection suspected:
Topical or oral antibiotics (e.g., cephalexin, clindamycin) guided by local guidelines.
If abscess forms:
Incision and drainage if fluctuant and not resolving.
If necrosis, systemic symptoms, or slow healing:
Urgent evaluation for possible spider bite, leishmaniasis, or atypical infection.
Tetanus prophylaxis should be up to date if skin broken.
---
4. When to Seek Immediate Medical Care
Rapid spreading redness or severe pain
Fever, chills, malaise
Expanding necrotic area
Lymphangitis (red streaks) or large lymph node swelling
---
If you want, I can create a decision flowchart for diagnostic and therapeutic steps to help guide further exploration.
Do you want me to make that flowchart?
[05-09-2025 13:16] +964 750 136 1306: You’re right to bring up cutaneous anthrax as part of the differential — especially since it can start like an insect bite but then develops a painless ulcer with a black necrotic center (eschar) and significant surrounding edema. Let’s analyze this possibility carefully:
---
Cutaneous Anthrax: Key Features
Typical lesion progression:
1. Starts as a small, pruritic papule (often thought to be an insect bite).
2. Within 1–2 days → vesicle or ulcer forms.
3. By day 3–7 → develops a painless black eschar with non-pitting edema around it.
Pain: Usually minimal or absent, unlike most infected insect bites.
Systemic symptoms: Sometimes mild fever, malaise, lymphadenopathy.
---
Clues favoring anthrax over a simple insect bite:
Painless black eschar instead of a painful lesion.
Marked edema that seems out of proportion to lesion size.
Occupational or environmental exposure: contact with animal hides, wool, livestock, or soil in endemic areas.
Multiple cases or local outbreak history.
---
Diagnosis
Gram stain & culture from vesicle fluid or eschar base → Bacillus anthracis (Gram-positive rods, non-motile).
PCR or ELISA for rapid confirmation.
Blood culture if systemic symptoms present.
---
Treatment (if suspected)
Antibiotics (start empirically if suspicion is high, don’t wait for confirmation):
Ciprofloxacin or doxycycline are first-line for uncomplicated cutaneous anthrax.
If systemic involvement suspected → add IV options (e.g., ciprofloxacin + one or two additional agents like clindamycin).
Do NOT excise the lesion; it heals after antibiotic therapy, sometimes leaving a scar.
Supportive care for systemic symptoms.
Notify public health authorities if suspected due to possible zoonotic or bioterrorism implications.
---
Key Differentiator from the Image
From your photo:
There is a small central dark area, but I cannot confirm if it’s a true black eschar versus crusted ulcer.
The surrounding edema doesn’t appear massive.
Anthrax lesions are usually painless; pain suggests more likely bacterial cellulitis/abscess rather than anthrax.
---
Here’s what I suggest:
Ask about pain, systemic symptoms, and exposure history.
If there’s painless black eschar + animal exposure or endemic area, test for anthrax immediately and start empiric antibiotics.
---
If you want, I can make a side-by-side table comparing insect bite, bacterial abscess, spider bite, and cutaneous anthrax for clearer differentiation.
Do you want me to prepare that table?
[05-09-2025 13:18] PPM 4: Here’s a clear side-by-side comparison of common causes of lesions that can look like an insect bite, including cutaneous anthrax:
Feature Simple Insect Bite Bacterial Abscess/Furuncle Spider Bite (e.g., Loxosceles) Cutaneous Anthrax
Onset Sudden, after bite/exposure Gradual, after folliculitis/trauma Sudden, after spider bite Papule → vesicle → ulcer over 2–5 days
Pain Often itchy or mildly painful Usually painful, throbbing Painful, especially necrosis Usually painless or mildly tender
Lesion center May have small punctum Pus-filled, may rupture Necrosis with ulceration possible Black eschar (dead tissue)
Surrounding tissue Mild redness/swelling Warm, red, inflamed (cellulitis) Swelling, redness, sometimes necrosis Marked, non-pitting edema
Discharge Rare, clear fluid if any Purulent discharge common May ooze necrotic tissue Usually dry ulcer, no pus
Systemic symptoms Rare, unless allergic reaction Fever, malaise possible Fever, malaise if severe envenomation Fever, malaise sometimes present
Progression Heals quickly May form abscess needing drainage May expand rapidly if venomous Spreads locally; untreated → slow healing
Epidemiology Common, anywhere Common, staphylococcal skin flora Endemic areas, spider exposure Animal/wool exposure, endemic zones
Diagnosis Clinical Clinical + culture if abscess Clinical, sometimes exclusion Culture/PCR from lesion base
Treatment Symptomatic: antihistamines Incision & drainage + antibiotics Wound care, sometimes antivenom Ciprofloxacin or doxycycline empirically
---
Key takeaways for your case
Painful, red, with pus → likely abscess or infected bite.
Painless, black eschar with massive swelling → think cutaneous anthrax, especially if animal exposure.
Rapid necrosis with severe pain → possible spider bite.
If you want, I can make a diagnostic flowchart to guide when to suspect anthrax and when to treat as a simple bacterial infection.
Do you want me to create that flowchart?
[05-09-2025 13:26] PPM 1: Thanks. Yes we are waiting for the history details from @~Dr.T
[05-09-2025 13:27] PPM 3: I'm gonna create a parallel group with patient
We (all Drs can discuss here)
any advice (preferably in kanada hindi) will be given in that parallel group
[05-09-2025 13:28] PPM 1: Yes very good plan
[05-09-2025 13:29] PPM 3: PA didn't reply yet sir
she is probably weak from her symptoms
will update if she or her daughter replies
she said she doesn't have anyone currently near her to look after her
And she sent this note given in jipmer
they haven't made any diagnosis yet
she is using antibiotics course now
[05-09-2025 15:54] PPM 3: Another volunteer mentioned
they said it is "scrub typhus"
[05-09-2025 16:12] PPM 1: Yes looking at that lesion, herald patch is the first thing that came to mind and hence the history that we now having puts the clinical findings in context!
@Meta AI @PPM4 what is the sensitivity specificity of herald patch in the diagnosis of scrub typhus as it's a very commonly used tool in India
[05-09-2025 16:12] Meta AI: Scrub typhus diagnosis in India, fascinating topic! The herald patch isn't typically associated with scrub typhus; it's more commonly linked to pityriasis rosea. Scrub typhus diagnosis often relies on clinical presentation, like fever, headache, and rash, alongside eschar formation, not herald patch. For scrub typhus, the eschar's sensitivity and specificity vary, but it's considered a key diagnostic clue. If you're looking for precise sensitivity and specificity numbers for eschar in scrub typhus diagnosis, those can vary across studies, but eschar is generally considered a specific sign. Want more details on scrub typhus diagnosis or clinical findings?
[05-09-2025 16:13] PPM 1: @Meta AI thanks for correcting. Yes I meant eschar not herald patch!
[05-09-2025 16:13] Meta AI: Glad to clarify! Eschar's a crucial diagnostic clue for scrub typhus. Studies show eschar's sensitivity ranges from 46% to 97%, while specificity's generally high, often above 90%. Variability's due to differences in study populations, diagnostic criteria, and disease stages. In India, where scrub typhus's endemic in certain regions, clinicians heavily rely on eschar, alongside clinical presentation and lab tests, for diagnosis. Accurate diagnosis is key for timely treatment. Want more insights on scrub typhus management or regional epidemiological data?
[05-09-2025 16:23] PPM 4: Of course. The clinical finding you're referring to, commonly called a "herald patch" in some regions, is more accurately known as the *eschar* in the context of scrub typhus. It is indeed a critical clinical clue.
Based on the search results, here is a detailed breakdown of its diagnostic utility, particularly in the Indian context.
### ⚕ 1. Definition and Pathognomonic Nature
The eschar is a necrotic skin lesion that develops at the site of the chigger bite. It begins as a papule, then ulcerates, and forms a black, crust-like scab with an erythematous halo. It is often described as resembling a cigarette burn.
The eschar is considered *pathognomonic* for scrub typhus, meaning its presence is a definitive sign of the disease.
### 📊 2. Sensitivity (Rate of Detection in Confirmed Cases)
The sensitivity of the eschar—meaning the percentage of confirmed scrub typhus patients who have one—is *highly variable and heavily influenced by geography and population*. It is not a consistently sensitive sign.
* *Wide Variability (7% - 97%):* The search results consistently report that the presence of an eschar in scrub typhus patients varies enormously, from as low as *7% to as high as 97%* across different endemic areas.
* *Specifically in Indian Populations: The sensitivity is reported to be relatively low.* The search results explicitly state that there is a "relative absence of eschar in the Indian population" .
* *Specific Data from India:* A study in Mizoram, Northeast India, found an eschar presence of only *4.74%* (12 out of 253 patients with acute febrile illness) .
* *Improvement with Thorough Examination:* One study noted that their eschar detection rate improved from less than 10% to *55%* simply by implementing a more thorough physical examination, highlighting that its apparent sensitivity depends heavily on clinician diligence .
### 🎯 3. Specificity (Accuracy in Ruling Out Other Diseases)
While its sensitivity is low, the *specificity of the eschar is very high*.
* *High Specificity:* When an eschar is found in a patient with acute febrile illness in an endemic area, it is strongly indicative of scrub typhus. The search results label it as a "distinctive clinical feature" and "pathognomonic" .
* *Differential Diagnosis:* It is important to rule out other conditions that can cause similar lesions, such as:
* *Anthrax:* However, an anthrax eschar is typically surrounded by extensive, gelatinous edema .
* *Spider bites.*
* *Post-traumatic scabs* .
### 📍 4. Reasons for Variable Presence and Detection in India
The search results provide several reasons for the low and variable sensitivity of the eschar in India:
1. *Skin Tone:* Eschars are more easily visualized on fair-skinned individuals than on those with darker skin complexions, which can make them harder to detect in many Indian patients .
2. *Location on Body:* Eschars are frequently found in hidden, intertriginous areas like the axillae, groin, under the breasts, perianal region, and waistband area. Without a meticulous, full-body examination, they are easily missed .
3. *Regional Variations in Orientia Strains:* The antigenic diversity of O. tsutsugamushi strains (e.g., Karp, Kato, Gilliam) varies across India, and some strains may be less likely to cause a classic eschar .
4. *The eschar can slough off* or be removed by scratching or bathing before the patient presents to a doctor .
### 💎 5. Clinical Implication and Utility as a Diagnostic Tool
* *Rule-In, Not Rule-Out:* The eschar is an excellent *"rule-in"* tool. Its presence allows a clinician to make a presumptive diagnosis and start life-saving antibiotics immediately.
* *Poor Rule-Out Tool:* The *absence of an eschar cannot rule out scrub typhus*. Given its low sensitivity in India, over-reliance on its presence for diagnosis will lead to a majority of cases being missed.
* *Must Prompt Treatment:* The consensus across all search results is that treatment with doxycycline (or azithromycin) should *never be withheld* pending diagnostic tests if scrub typhus is clinically suspected, regardless of whether an eschar is found.
To summarize the sensitivity and specificity of the eschar in India:
| Metric | Estimate for Indian Population | Key Supporting Evidence |
| :-------- | :-------------------------------------------------------------------------------------------------------------------------- | :--------------------------------------------------------------------------------------------------------------------------------------------------- |
| *Sensitivity* | *Low and Highly Variable* (Reported from *<10% to ~55%*; often cited as "relatively absent") | |
| *Specificity* | *Very High* (Considered *pathognomonic*; its presence is a definitive sign in the right clinical context) | |
### 🔬 Conclusion: Beyond the Herald Patch - The Need for Laboratory Confirmation
While the eschar (herald patch) is a invaluable and pathognomonic sign when present, its *low sensitivity in the Indian population means it is an unreliable standalone diagnostic tool.*
A diagnosis of scrub typhus should be based on a combination of:
1. *Clinical Suspicion:* Fever, headache, myalgia in an endemic area.
2. *Epidemiological Clues:* Exposure to rural/grassy areas, especially during the rainy season.
3. *Supportive Lab Findings:* Thrombocytopenia, elevated transaminases.
4. *Laboratory Confirmation:* The mainstay of diagnosis, especially in eschar-negative cases, is serological testing. The recommended tests are:
* *IgM ELISA:* Cited as having excellent sensitivity (92-99.9%) and specificity (94-99.7%) and is more feasible than IFA for most Indian laboratories.
* *Immunofluorescence Assay (IFA):* Remains the reference standard but is costly and not widely available.
* *PCR:* Excellent for early diagnosis (97% sensitivity, 100% specificity) but is primarily available in reference laboratories.
In conclusion, the eschar is a classic sign that puts the clinical picture in context, as you experienced, but in India, its absence is far more common than its presence. *Presumptive treatment based on clinical suspicion is paramount, and diagnosis should be confirmed with serological tests like IgM ELISA.*
[05-09-2025 16:28] PPM 3: 63 F yrs
Insect bite- 15 days back
swelling in eyes
Headache
Body pains (more ear pain, mouth, face, eyes)
Stomach pain
feeling off
Low energy
thought low bp
had salt water
severe headache
2 days later
blood test
Diagnosis: scrub typhus
insect name /pic:
[05-09-2025 16:28] PPM 3: RFT?
all test normal
[05-09-2025 16:28] PPM 3: Better than yesterday
[05-09-2025 16:28] PPM 3: Yesterday low energy
today better
[05-09-2025 16:29] PPM 3: I was totally wrong with the Age estimation 😅
she said she is 63 yrs sir
[05-09-2025 16:29] PPM 3: She was prescribed with doxycycline tabs BD
i suggested pantop before breakfast sir
[05-09-2025 16:30] PPM 1: Ask her to take plenty of water to ensure the doxycycline is ingested well else it's notorious for causing pill induced esophageal ulcerations
[05-09-2025 16:31] PPM 3: Yes sir sure
[05-09-2025 16:32] PPM 4: Yes, at least 2 glasses of water and she should avoid sleeping or bending for at least 2 hours for the same reason.
[05-09-2025 16:33] PPM 3: okay sir
~26th Aug
[06-09-2025 21:36] PPM 3: PA says patient feels better and being idle doesn't help so she did some work today and saying that's the same mite that has bit her (pic) sir
[07-09-2025 18:49] PPM 3: today's update explained by her daughter
[07-09-2025 18:52] PPM 3: Today is the last day of Her 4 day antibiotic course
aunty is still feeling weak..
even her voice seems pretty dull than her original self.
Guess she is concerned she is not back to her original self yet
[10-09-2025 08:12] PPM 1: 👆 deleted the above as it contained patient identifiers but transferred it to the core group for further processing. @CR @PPM4@PPM5@PPM6 while we emphasize many other parameters to be entered in the consent form but it's possible that the current structure of it's text somehow makes most users miss filling in all the data points as what is often stated in our PaJR flyer as below 👇
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