Figure 6 - available via license: Creative Commons Attribution 4.0 International
Content may be subject to copyright.
Source publication
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 prospe...
Citations
... Atypical manifestation of SFG is not uncommon and often overlooked. 6 We documented a series of patients with neurological manifestations where extrapyramidal manifestations such as bradykinesia and tremors were observed in elderly patients. 7 In a series of patients with obscure lower motor facial nerve palsy with otoacariasis collected prospectively over 16 years from the ENT clinic Kandy, we found SFG aetiology. ...
... PCR-based molecular studies conducted using skin lesion biopsies from patients, successfully identified the 17-kDa spotted fever group-specific antigen. 6 Currently, NSF funded project in collaboration is investigating the SFG rickettsial agents with shared vectors, reservoir hosts, and phylogenetic affinities of the pathogen in humans. The study of 847 ticks in the CDC, Atlanta identified 5 genotypes of spotted fever rickettsial agents indicating the involvement of many spotted fever agents causing human infection. ...
... 16 The descriptions of Sri Lankan patients with SFG rickettsioses includes some severe clinical manifestations, including the development of acute vasculitis, arthritis, and fern leaf skin necrosis. 7,8,17,18 To date, there are only two publications reporting polymerase chain reaction (PCR)-based diagnostic findings in febrile patients from Sri Lanka. 18,19 The first article reports detection of the 17-kDa SFG specific protein antigen gene in the skin biopsies of patients with fern leaf necrosis 18 ; however, the specific etiological agent is uncertain because of significant genus-level nucleotide sequence conservation of this gene among SFG rickettsiae. ...
... 7,8,17,18 To date, there are only two publications reporting polymerase chain reaction (PCR)-based diagnostic findings in febrile patients from Sri Lanka. 18,19 The first article reports detection of the 17-kDa SFG specific protein antigen gene in the skin biopsies of patients with fern leaf necrosis 18 ; however, the specific etiological agent is uncertain because of significant genus-level nucleotide sequence conservation of this gene among SFG rickettsiae. 20,21 A second article described a returning traveler from the jungle of Sri Lanka who allegedly experienced a febrile illness with enlarged lymph nodes, a maculopapular rash, and an eschar; this patient tested PCR positive for Rickettsia sibirica mongolotimonae, 19 although the sequence of the amplicon was not provided for analysis and comparison. ...
... 7,8,17,18 To date, there are only two publications reporting polymerase chain reaction (PCR)-based diagnostic findings in febrile patients from Sri Lanka. 18,19 The first article reports detection of the 17-kDa SFG specific protein antigen gene in the skin biopsies of patients with fern leaf necrosis 18 ; however, the specific etiological agent is uncertain because of significant genus-level nucleotide sequence conservation of this gene among SFG rickettsiae. 20,21 A second article described a returning traveler from the jungle of Sri Lanka who allegedly experienced a febrile illness with enlarged lymph nodes, a maculopapular rash, and an eschar; this patient tested PCR positive for Rickettsia sibirica mongolotimonae, 19 although the sequence of the amplicon was not provided for analysis and comparison. ...
Because the majority of spotted fever group rickettsiae are transmitted to humans by tick bites, it is important to understand which ticks might play a role in transmission of rickettsial pathogens in Sri Lanka. The purpose of our study was to conduct molecular surveillance of 847 ticks collected in different locations in central Sri Lanka to determine which were infected with Rickettsia and Anaplasmataceae. Molecular methods were used to identify the ticks and the agents detected. Most ticks ( Amblyomma , Haemaphysalis , and Rhipicephalus ) were collected by flagging, and lower number was collected from dogs, cattle, pigs, a pangolin, and tortoises. Five spotted fever genotypes were identified: a Rickettsia africae- like agent in Amblyomma larvae, Rhipicephalus massiliae and a related genotype identified in association with the tropical type of Rhipicephalus sanguineus from dogs and Rhipicephalus haemaphysaloides from dogs and cattle, and Candidatus R. kellyi and another novel genotype (SL94) in R. haemaphysaloides. Twenty-three ticks were positive for Anaplasmataceae, including one Anaplasma and two Ehrlichia genotypes. Because the sequence database for both ticks and rickettsial agents from Sri Lanka and southern India is not extensive, additional molecular characterization of the tick species of Sri Lanka and their rickettsial agents is required to understand their pathogenic potential more completely. However, several of the agents we identified in this survey may well be pathogenic for humans and domestic animals, and should be considered as a part of epidemiological surveillance and patient management.
... Different studies have used a different cut-off for STG and SFG [6,10,11]. For IFA baseline cut-off titer was calculated to be 1:128 and 1:64 for SFG IgG and IgM respectively [12]. In other studies 1:32 both IgG and IgM for SFG and 1:128 for STG IgM was used as cut-off titer [10] (12). ...
... For IFA baseline cut-off titer was calculated to be 1:128 and 1:64 for SFG IgG and IgM respectively [12]. In other studies 1:32 both IgG and IgM for SFG and 1:128 for STG IgM was used as cut-off titer [10] (12). Most of the studies have determined cut-off for Weil Felix, ELISA and IFA for STG only. ...
Purpose
The clinical manifestations of rickettsial diseases mimic other endemic infections with similar presentations thus posing a serious challenge to clinicians for their diagnosis. For the diagnosis of rickettsial disease serological tests like Weil Felix, ELISA and IFA are used. There are limited studies that have evaluated different serological tests for the diagnosis of rickettsial diseases. Therefore, the present study was undertaken to evaluate the ELISA and Weil Felix test for the diagnosis of rickettsial diseases prevalent in this region.
Methods
Samples from 281 patients clinically suspected of rickettsial diseases were tested for spotted fever group (SFG), typhus group (TG) and scrub typhus group (STG) by Weil Felix, ELISA and IFA was taken as the gold standard. Baseline titers and cut-off ODs were calculated by taking samples from healthy blood donors.
Results
The sensitivity, specificity, positive and negative predictive value of Weil Felix test ranged from 30% to 44%, 83.46%–97.86%, 9%–77%, 92–96% respectively. The sensitivity and specificity, positive and negative predictive value of ELISA ranged from 80.77% to 96.15%, 96.33%–98.43%, 70.21%–88.64%, 92.89%–99.60% respectively. Maximum cross-reactions were observed between SFG and STG by the Weil Felix test and between STG and TG by ELISA.
Conclusions
ELISA was found to be sensitive and specific for the diagnosis of rickettsial diseases. It is easy to perform, does not require a technical expert for result interpretation and a large number of samples can be processed at a time.
... Our data suggest a strong association of rash on the palms and soles, in an individual with a febrile rash, with a diagnosis of spotted fever. These findings are similar to that reported earlier from our center [8,29] and by others [30][31][32]. ...
Spotted fever (SF) is an important treatable cause of acute febrile illness (AFI) with rash and has reemerged in India. A prospective AFI with rash study was undertaken at a South Indian hospital to correlate specific clinical findings with laboratory confirmation of spotted fever. During the study period (December 2017 to May 2019), 175 patients with fever and rash were suspected to have spotted fever. Molecular assays for scrub typhus and spotted fever (47 kDa and ompA qPCR) and serology (IgM ELISA) was performed on the 96 individuals recruited. Laboratory confirmed SF cases (ompA qPCR positive) were 21, whereas laboratory supported SF cases (ompA negative but sero-positive by SF IgM ELISA) were 27. Among the 48 spotted fever (SF) cases, 70% of had maculopapular rash, 12.5% had macular rash, purpuric/petechial rash (severe rash) was seen in 8 patients (16.7%). Presence of rash on the palms and soles was associated with a relative risk (RR) of 4.36 (95% CI: 2.67–7.10; p < 0.001). Our study suggests that ompA qPCR though useful for confirming the diagnosis of spotted fever is not always positive. A positive SF IgM ELISA in febrile individuals with palmo-plantar rash supports the diagnosis of spotted fever especially when other causes of febrile rash have been excluded. Multi-centric prospective studies employing the serological reference standard, IFA (immunofluorescence assay) in addition to the assays used in this study are needed to validate these findings.
... Early reports of rickettsial infections in Sri Lanka found that tick-borne spotted fever group (SFG) infection is widely distributed in the hilly central province of the island. 1,2 Classically, patients with SFG rickettsioses present with fever and a skin rash. Fever is generally of abrupt onset and is high grade and intermittent, and the skin rash is erythematous and maculopapular, often with the presence of eschar. ...
... Fever is generally of abrupt onset and is high grade and intermittent, and the skin rash is erythematous and maculopapular, often with the presence of eschar. [1][2][3][4] In most cases of SFG rickettsial infections, history of tick bite is obscure and eschars are not apparent. Therefore, the link of the 2 entities is not very apparent. ...
... 3,4 Today, rickettsial infections are endemic in Sri Lanka and burden the health care system with an increasing number of cases. 1,2,5 The aim of this case report is to show the burden of tick infestation in the highlands of Sri Lanka and its direct link to SFG, a diagnosis often overlooked. ...
Tea plantations in Sri Lanka cover the central hills of the island, where spotted fever group (SFG) rickettsial infection is common. In most cases, the history of tick bite is obscure and eschars are not present. A 45-y-old female experienced massive tick bites while working in her tea plantation. She developed fever 2 d after exposure, but the diagnosis of SFG infection was not considered until a skin rash appeared on the eighth day. She had a very high titer of antirickettsial antibodies detected by immunofluorescence assay and responded to doxycycline. Here, we highlight the high risk of exposure to ticks and tick bites within tea estates and its causal relationship to SFG infection, which is increasing in Sri Lanka. Active case detection, notification, surveillance, and community awareness are imperative. Possible preventative measures for tick bites have to be introduced. There is a need to explore the effectiveness of local remedies currently in use.
... Commonly, the spotted fever rickettsial infection has a typical picture of cutaneous manifestations with arthritis frequently involving ankle joints [5,6]. Delay in diagnosis could cause fatal multiple organ dysfunction involving liver [7,8]. ...
... Spotted fever is a group of infections caused by many species of rickettsial agents distributed widely in the world [1,2]. There may be more than one species of rickettsial agents existing in Sri Lanka causing different clinical manifestations [5,6]. ...
We present a rare case of a 31-year-old pregnant mother in 37 weeks of gestation who presented with a 3-day history of vomiting, epigastric pain, and icterus, subsequently diagnosed as a rickettsial disease in pregnancy (with positive IgG titer for SFG) complicated with hepatitis, coagulopathy, pulmonary hemorrhage, and post-partum hemorrhage, who expired despite intensive care management. The newborn baby also had high IgG titer for SFG suggesting a vertical transmission of the disease and recovered following treatment with chloramphenicol. The SFG rickettsial infection can cause diverse clinical manifestations in pregnancy including acute Case Study Ratnayake et al.; AJRID, 7(3): 1-5, 2021; Article no.AJRID.70843 2 hepatitis and coagulopathy. Therefore, the possibility of SFG rickettsial infection needs to be considered in diagnostic workup in obscure clinical presentations. We postulate possible vertical transmission of SFG to newborns which needs further confirmation.
... The proportion of patients with spotted fever presenting with rash has varied from 16% to 100%. 21,34 Eschar is rarely associated with spotted fever. 18,21,24 However, in the outbreak of rickettsioses in the Kilinochchi area mentioned above, a considerable proportion of patients with serological evidence of spotted fever had demonstrated an eschar like lesion, particularly in the eye. ...
... Involvement of palms and soles had been noted in about 50% of the study group. 34 Variations in the skin involvement has been described in Sri Lanka, and it is important for treating clinicians to be aware of these differences in order to initiate prompt treatment. Alternative types of rashes that have been reported include fern-leaf pattern skin necrosis 35 and purpura fulminans. ...
Rickettsioses are a group of vector-borne diseases that have come to the limelight in Sri Lanka during the last two decades. Evidence for spotted fever group rickettsioses, scrub typhus and other related diseases have been reported from Sri Lanka in a geographically restricted manner. This review summarizes the work done locally, that are publicly accessible as of 24th November 2018 with keyword searches ‘rickettsioses and Sri Lanka’, and ‘typhus and Sri Lanka’, on PubMed and Google Scholar. There is a considerable body of literature on rickettsioses in Sri Lanka, particularly as a result of collaborations with international research groups. These indicate that rickettsioses are found throughout the country, in a geographically restricted manner.
... In severe cases fern leaf type skin necrosis can occur. The typical eschar is rare to be found and often the patients are unaware of of tick bites [1,4]. On rare occasions patients present with fever and multiple organ dysfunction making it difficult for the clinician to find the exact diagnosis since many tropical diseases can cause a similar picture. ...
Background
Spotted fever group of rickettsial infections are emerging in Sri Lanka. We describe a patient with rapidly progressing ARDS and myocarditis secondary to spotted fever caused by Rickettsia conorii. ARDS and myocarditis are rare complications of Rickettsia conorii infections and only a few cases are reported to date.
Case presentation
A 53 years old manual worker presented with fever for 5 days and a skin rash. He was in circulatory failure on admission and developed severe hypoxaemia with gross changes in chest radiograph by next day requiring assisted ventilation. He had myocarditis causing left ventricular failure and acute respiratory distress syndrome. He was confirmed to have spotted fever rickettsial infection with rising titre of indirect immunofluorescence antibodies to Ricketssia conorii and made a complete recovery with appropriate antibiotic therapy and supportive care.
Conclusion
Rickettsial infections can present with diverse manifestations. Even the patients with severe organ involvements such as myocarditis and ARDS can be completely cured if timely identified and treated.
... With the changing pattern of ecology and diseases as mentioned above, it is possible that some ticks infected with rickettsial pathogens could cause otoacariasis. Many patients who present with spotted fever rickettsioses has a history of previous tick bite and it hardly produces local eschar [15,46]. But the pathogens multiply at the tick bite site and gradually lead to systemic disease. ...
Background:
Over the last two decades intra-aural tick infestation (otoacariasis) has been a common occurrence in the hilly central region in Sri Lanka. Very occasional detection of isolated unilateral facial nerve palsy associated with otoacariasis attributed to toxin damage of the nerve prompted us to study the clinico-epidemiology and aetio-pathology of the problem.
Methods:
All cases having isolated unilateral facial nerve palsy associated with otoacariasis presented to, Ear Nose and Throat clinic at General Hospital Kandy, Sri Lanka from 2001 to 2016 were included in the study. The facial palsies were assessed with nerve conduction studies and, harvested ticks were identified.
Results:
There were 29 patients with mean age of 46 years (range 22-76 years) with male to female ratio of 1:1.9. First 12 patients without specific treatment took 1-55 months for recovery and 4 had axonal degeneration. Last 5 patients were treated with doxycycline and recovered in 4 weeks. They had strong sero-conversion of immunofluorescence antibodies against spotted fever rickettsioses and the tick harvested from the last patient was PCR positive for rickettsial DNA. Identified ticks belonged to Dermacentor, Amblyomma, Rhipicephalus and Hyalomma species.
Conclusions:
On contrary to popular toxin theory, we were able to demonstrate treatable rickettsial aetio-pathology as the cause of otoacariasis associated lower motor facial palsy in Sri Lanka.
... Rickettsial infections can present with various cutaneous manifestations. The typical features of the skin rash include discrete macular-papular lesions with a dusky erythematosus hue, distributed mainly in the limbs, the back of the chest, the anterior abdomen, and the soles of the feet [10]. However, there are many other variations, including fern leaf pattern skin necrosis, patchy necrotic lesions, and cutaneous edema [10]. ...
... The typical features of the skin rash include discrete macular-papular lesions with a dusky erythematosus hue, distributed mainly in the limbs, the back of the chest, the anterior abdomen, and the soles of the feet [10]. However, there are many other variations, including fern leaf pattern skin necrosis, patchy necrotic lesions, and cutaneous edema [10]. Identification of cutaneous lesions in rickettsial infections plays a pivotal role in making a diagnosis early. ...
Background
Purpura fulminans is an acute life-threatening disorder characterized by intravascular thrombosis and hemorrhagic infarction of the skin complicated with disseminated intravascular coagulation. It is commonly seen in acute infections following meningococcal and streptococcal infections. Few cases of purpura fulminans following rickettsial infections have been described in the literature.
Case presentation
We report a case of a 55-year-old Sri Lankan woman who presented to Teaching Hospital Peradeniya with a febrile illness, headache, and myalgia that progressed to an erythematous rash starting over the bilateral lover limbs and hands and that became black and necrotic with a few hemorrhagic blebs. She had normocytic anemia, platelet clumps, and monocytosis as well as a deranged clotting profile. The result of immunofluorescence antibody testing for rickettsial immunoglobulin G was strongly positive for Rickettsia conorii with a rise in titer convalescent sera, and a diagnosis of purpura fulminans following rickettsial infection was made. The patient made an excellent recovery with chloramphenicol treatment.
Conclusions
The treating physician should consider the rare but very treatable condition of rickettsial infection as a differential diagnosis in the etiological diagnostic workup of patients presenting with severe purpuric and hemorrhagic rash with fever.
