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case_images: MRI of the brain: (A and B) Are MRT1 and T2 FLAIR of the brain, (C) is MRSWI of the brain, and (D) Is MRDWI of the brain. Multiple patchy long T1 and long T2 signal foci are observed in the bilateral Corona radiata and frontal lobes, with high signal in the periventricular space and no evident high signal in DWI. The ventricular system is dilated, and the cerebral sulci and fissures show no significant widening or deepening. The midline structures are centered. Honeycomb-like long T1 and long T2 signal are observed in the bilateral mastoid cells. On SWI, a small round low signal is seen in the left frontal lobe; no significant abnormal high signal is observed in DWI.
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case_images: Brain MRI revealed multiple ischemic lesions, bilateral mastoiditis, and slight bleeding in the left frontal lobe, with no significant abnormality on DWI (Figure 1). 
case_images: Microscopic examination of cerebrospinal fluid (CSF) cells: The microscopic examination of the cerebrospinal fluid as shown in (A and B) Reveals a mixed-cell reaction type predominantly composed of lymphocytes.
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case_images: The tryptophan test was positive (Figure 2).
case_images: mNGS testing: (A) mNGS results of cerebrospinal fluid indicate Orientia tsutsugamushi, with a total of 2 sequences detected (average sequencing depth of 1X; genome coverage of 0.4978%). (B) Displays the classification of viral sequences for each specific virus.
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case_images: With the consent of the patient and family, the cerebrospinal fluid sample was sent for mNGS testing, which detected 2 reads of specific sequences of Orientia tsutsugamushi (Figure 3), which resulted in a diagnosis of Orientia tsutsugamushi encephalitis.
case_images: Patient's visit timeline.
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case_images: The progress of patients during hospitalization was summarized in Figure (Figure 4).   