A 22-year-old female, living in a village in northeast India presented with, high grade, continuous fever for five days, associated with headache and myalgia. Fever was followed by irrelevant talks and alteration in sensorium. There was no history of seizure or vomiting. She also developed yellowish discolouration of sclera. There was no past or contact history of tuberculosis. On examination, patient was febrile and had altered sensorium. Pulse rate was 100/ minute, regular, BP-110/70 mm Hg, respiratory rate-24/minute. The patient had a dark, hyperpigmented, raised, patch in left infraaxillary region suggestive of an eschar [Table/ Fig-1]. Respiratory system, cardiovascular system and per abdominal examination were non contributory. On neurological examination, higher mental function was impaired in the form of disorientation and clouding of consciousness. Plantar reflex was flexor bilaterally. Cranial nerve examination revealed bilateral lateral rectus palsy [Table/ Fig-2]. Investigations showed Hb-9.3 gm%, total leucocyte count-6000/cumm, platelets-1.9 lacs/cumm, PCV-28%, ESR-70mm/h. Peripheral blood smear showed normocytic normochromic anaemia with relative lymphocytosis. Malaria parasite slide and dual antigen were negative. Liver function test revealed total bilirubin-3.2mg/dl, direct bilirubin-1.5 mg/dl, SGOT-169 U/l, SGPT-91 U/l, albumin-2.4 gm/dl, globulin-4.9 gm/dl. Blood for HbsAg, anti HCV, HIV-1 and HIV-2 antibody were negative. Dengue NS-1 antigen and IgM, IgG anti-dengue antibody by ELISA were also negative. Urea-22 mg/ dl, creatinine-0.5 mg/dl. Widal test was negative. Chest X-ray was normal. Sonography of abdomen revealed mild hepatosplenomegaly with minimal right sided pleural effusion. Cerebrospinal fluid study showed cell count-3/cumm predominantly lymphocytes, glucose 54mg/dl, protein-117 mg/dl, Adenosine Deaminase (ADA) below 10 U/l. MRI of brain with contrast was normal. Considering patient's area of living, clinical presentation of fever and skin lesion, blood test to confirm scrub typhus (IgM) was sent which came out to be positive on immunofluorescence assay. Skin biopsy showed extensive dermal necrosis with small vessels of the upper and lower dermis showing necrotizing vasculitis with perivascular lymphocytic and neutrophilic infiltrate. There was extravasation of red blood cells and evidence of luminal thrombosis and also there were zones of infarction . Features were in favour of typical eschar (Doxycycline to be considered after confirmation of diagnosis). She responded on third day with improvement in sensorium however she developed diplopia and her lateral rectus palsy persisted. The patient was given a full course of doxycycline along with azithromycin with occular movement exercises and discharged with an advice to follow up in outpatient department. Scrub typhus, a rickettsial disease is endemic in several parts of India usually presenting with acute symptoms. Fever, maculopapular rash, eschar, history of tick exposure and supportive diagnostic tests usually leads to diagnosis...