• Je Yeon Byeon, Hyun Kim, Da Woon Lee, and Hwan Jun Choi.
• Department of Plastic and Reconstructive Surgery, College of Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea.
• Medicine (Baltimore). 2023 Nov 10; 102 (45): e36009e36009.

RationaleTsutsugamushi disease is a common infectious disease in the Northern Hemisphere. A patient infected with tsutsugamushi disease will show a characteristic clinical course with eschar formation, which is mostly small and self-limited in nature without causing major problems. We report a rare case of unusually extensive necrosis started from a small eschar.Patient ConcernsIn this report, a 65-year-old female patient with a history of diabetes mellitus present an 8 × 6 cm-sized huge eschar and extensive soft tissue necrosis aggravated from a small eschar. Also, there were 3 other small eschars in the scalp and left flank area. In early July, she was farming in a field in Hongseong-gun, South Korea. She had been treated at another hospital for 2 weeks. However, the eschar became bigger and worse.DiagnosesAfter admission, escharectomy was performed and extensive soft tissue necrosis was identified. Orientia tsutsugamushi antibody tests were positive from blood test. Providencia rettgeri and Enterococcus faecalis were detected in a tissue bacterial culture test.InterventionWhile using oral azithromycin and intravenous imipenem/cilastatin, the necrosis of the thigh was excised and covered by lateral femoral circumflex artery based myocutaneous Keystone flap.OutcomesThe remaining small eschars recovered spontaneously, the large eschars that had caused necrosis were successfully treated, and all other clinical symptoms improved without complications.LessonsFor unusual eschar of an unknown cause, especially in patients with uncontrolled diabetes or immunocompromised, the possibility of Tsutsugamushi should be considered. Careful physical examination and proper management should be performed as soon as possible.Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.

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