急性溶血性貧血，黃疸通常是輕度的，且以間接膽紅素為主，末梢網狀紅血球在急性溶血後三至五天內會代償性升高。恙蟲病是一種以恙蟲為媒介的地方性（endemic）急性感染性疾病，延誤診斷與治療可能導致死亡。一位64 歲女性因右下肢一外傷性傷口逐漸惡化住院治療。住院時無黃疸或貧血，住院後，傷口清創，並給予抗生素oxacillin 治療；一、二週後，病人變得明顯喘促、呼吸困難、全身虛弱、蒼白、發燒、尿量減少，並出現重度黃疸和嚴重貧血，血液白血球計數：17,410/μL，血色素：5.8gm/dL，血比容：17.8%；網狀紅血球計數：1%，血清麩胺酸苯醋酸轉氨酶：212U/L，血清麩胺酸丙酮酸轉氨酶：209U/L，總膽紅素：32.22mg/dL，直接膽紅素：17.1mg/dL，乳酸去氫酶：1115 U/L，血清結合球蛋白：<7.62μg/dL，直接和間接Coomb's 試驗皆呈強陽性反應，符合自體免疫溶血性貧血合併急性溶血的診斷，但超高的高膽紅素血症，多重器官衰竭和網狀紅血球計數減少則不完全符合自體免疫溶血性貧血的臨床表現，懷疑是一種混合型高膽紅素血症及骨髓無法代償性造血，另有感染原存在，故同時送檢恙蟲病間接螢光抗體試驗和real-time 聚合酶連鎖反應及微小病毒B19型專一性IgM 試驗等，結果皆呈陽性反應，確定為恙蟲病感染，及微小病毒B19型專一性IgM陽性反應，高度懷疑同時受到微小病毒B19型感染。立即給予doxycyclin 及輸血治療，病情逐漸改善，病人於第44 天出院。由於本病例臨床上特殊的呈現方式，我們建議臨床醫師不要忽略恙蟲病與微小病毒發生共同感染的可能性。

Acute hemolytic anemia generally induces modest elevation of serum bilirubin, composed primarily of unconjugated bilirubin, and mild jaundice. Blood reticulocyte count increases within 3 to 5 days following
hemolysis. Scrub typhus is an endemic infectious disease and may result in fatal outcome if diagnosis or treatment was delayed. A 64-year-old female with unknown history of autoimmune hemolytic anemia was admitted due to an accidental wound at the right lower leg; there was no anemia or jaundice on the admission day. the wound was debrided and oxacillin was prescribed; Two weeks later, the patient became severe dyspnea, general
weakness, pallor and fever; Oliguria, heavy jaundice and severe anemia were also noted; Blood WBC: 17,410/μL, hemoglobin:5.8gm/dL, hematocrit: 17.8%, reticulocyte count: 1%, reticulocyte production index: 0.13; GOT:
212U/L, GPT: 209U/L, total bilirubin: 32.22mg/dL, direct bilirubin: 17.1mg/dL,lactate dehydrogenase: 1115U/L, haptoglobin: ＜ 7.62μg/dL, direct and indirect Coomb's test were strong positive. all those presented were compatible with diagnostic criteria of autoimmune hemolytic anemia. however, because of the presence of an excess of hyperbilirubinemia, multiple organ failure and reticulocytopenia, other concomitant infections, such as scrub typhus and parvovirus B19, were considered. The serologic tests associated with scrub typhus and parvovirus B19 infection were performed and results as following: scrub typhus indirect fluorescent antibody-IgM (IFA-IgM）test positive, indirect fluorescent antibody-IgG (IFA-IgG) test positive and real-time polymerase chain reaction (real-time PCR) positive, established the scrub typhus infection, and parvovirus B19 specific IgM test positive, highly suspected concomitant infection of parvovirus B19. Doxycyclin and blood transfusion therapies were given immediately. The patient's general condition got improvement gradually and she discharged on the
44th day. Because of the specificity and complexity of this case, wesuggest clinicians not to forget the possibility of concurrent infection of Scrub typhus and Parvovirus B19 when clinical manifestations present as above.