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- Title
Cutaneous Manifestations of Spotted Fever Rickettsial Infections in the Central Province of Sri Lanka: A Descriptive Study.
- Authors
Weerakoon, Kosala; Kularatne, Senanayake A. M.; Rajapakse, Jayanthe; Adikari, Sanjaya; Waduge, Roshitha
- Abstract
Background: Characteristic skin lesions play a key role in clinical diagnosis of spotted fever group rickettsioses and this study describes these cutaneous manifestations along with basic histological features. Methods and Findings: Study was conducted at Medical Unit, Teaching Hospital, Peradeniya, from November 2009 to October 2011, where a prospective data base of all rickettsial infections is maintained. Confirmation of diagnosis was made when IgM and IgG immunofluorescent antibody titre of 1/32 and >1/256 respectively. Of the 210 clinical cases, 134 had cutoff antibody titers for Rickettsia conorii antigen for confirmation. All these 134 patients had fever and skin rash, and of them 132(98%) had discrete maculopapular rash while eight (6%) had fern leaf type skin necrosis. Eight patients (6%) had healed tick bite marks. Average size of a skin lesion was 5 mm and rash involved 52% of body surface, distributed mainly in limbs and back of the chest. Generally the facial and leg skin was slightly oedematous particularly in old aged patients. Sixteen patients (12%) had pain and swelling of ankle joints where swelling extended to feet and leg. Biopsies from skin rash of six patients showed evidence of cutaneous vasculitis and of them, 247 bp region of the 17-kDa spotted fever group specific protein antigen was amplified using PCR. Conclusions: A discrete maculopapular rash and occasional variations such as fern leaf shape necrosis and arthritis are found in spotted fever group. Histology found vasculitis as the pathology of these lesions. Author Summary: Rickettsial organisms infect humans causing a wider array of clinical features and have re-emerged in Sri Lanka where three known disease entities; spotted fever group, murine typhus and scrub typhus do exist. These diseases cause clinical illnesses varying from mild febrile illness to severe multiple organ involvement even leading to fatal outcomes when there is a delay in diagnosis. Occasionally, clinical features could be nonspecific or atypical. Nevertheless, detection of skin lesions mostly facilitates the clinical diagnosis. Hence, clinicians need to be familiar with common as well as uncommon variations of skin manifestations. Being a treatable infection, early diagnosis is important and is heavily based on clinical features in settings where laboratory diagnostics are unavailable; at the same time delaying of treatment could lead to high morbidity and mortality. We identified some important variations of skin lesions associated with spotted fever group rickettsial infections which include fern leaf type skin necrosis mainly involving superficial skin with blackish discoloration which dries up with time and peels off. In addition, mild cutaneous oedema is seen over the face and ankles especially in older patients. Acute arthritis involving ankle joints were common manifestations which together with typical skin lesions facilitate the clinical diagnosis.
- Subjects
SRI Lanka; RICKETTSIAL diseases; CUTANEOUS manifestations of general diseases; TSUTSUGAMUSHI disease; ANKLE joint; FEVER; DELAYED diagnosis
- Publication
PLoS Neglected Tropical Diseases, 2014, Vol 8, Issue 9, p1
- ISSN
1935-2727
- Publication type
Article
- DOI
10.1371/journal.pntd.0003179