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Rickettsial diseases in Brazil: report of a case with varicella-like skin lesions* * Work performed at Hospital São Francisco - Ribeirão Preto (SP), Brazil

Dear editor,

A 66-year-old male patient began to experience headache, fever, myalgia, and general malaise three days after returning from a farmhouse in São Sebastião do Paraiso, in the state of Minas Gerais, Brazil, where he stayed for five days. After five days, the patient reported cough, dyspnea, diarrhea, and rash, and was hospitalized for evaluation. Physical examination showed a BP of 130x80 mmHg, HR of 100 BPM, RR of 21 IPM, temperature of 38.5ºC, O2 Sat of 90% in ambient air, and O2 Sat of 94 % with 3L/min via nasal cannulae. The patient was in regular state and tachypneic. Respiratory auscultation showed bilateral crepitation. Dermatological examination revealed erythematous macules, papules, vesicles, pustules, and vesiculo-crusted lesions on the trunk, back, and in the cervical region. We also observed an erythematous papule topped by a vesicle showing a necrotic spot in the right scapular region (Figure 1). Chest x-ray performed on the third day of his symptoms revealed bilateral perihilar opacification. On the seventh day, however, another x-ray showed opacification of two thirds of the right lung. Chest tomography showed an alveolar lesion in the upper portion of the lower lobe of the right lung intermingled with air bronchogram extending to the pleural surface, in addition to paraseptal emphysema and pleural effusion. The patient had no clinical improvement after seven days of treatment with ceftriaxone (2g/daily), clarithromycin (500mg/twice daily), and acyclovir (5mg/kg/every eight hours) (Figure 2).

Figure 1
Polymorphous eruption (papules and erythematous macules, vesicles) predominantly on the trunk on the day of hospital admission. Note an erythematous papule with a raised vesicle showing a necrotic spot (arrow)

Figure 2
A and B. Maculopapular rash and varicelliform eruption. Presence of erythematous macules and papules, vesicles, and some exulcerated lesions with a A B necrotic center

An interconsultation with the dermatology department was then requested. Although the patient denied having had a tick bite during his stay in São Sebastião do Paraíso, the hypothesis of spotted fever was raised. We requested serology tests for spotted fever, viral hepatitis, herpes types 1 and 2, HIV, syphilis, and Lyme disease. We also biopsied two erythematous macules of the flanks. The patient showed positive serology results for spotted fever with anti-Proteus OX-2 antibody (1/160), anti-Proteus OX-19 antibody (1/160), and anti-Proteus OX-K antibody (1/160 ). Serology tests for hepatitis A, B, and C, herpes types 1 and 2, HIV, syphilis, and Lyme borreliosis were negative. Histopathological examination of the lesions showed a hydropic degeneration of basal cells with subepidermal clefts and detachment of parts of the epidermis. We also observed individual and confluent necrosis of keratinocytes with accumulation of neutrophils, fibrin, and crusts. The dermis showed perivascular and superficial inflammatory lymphomononuclear interstitial infiltrates. Vacuolar dermatitis of interface with keratinocyte necrosis was thus revealed (Figure 3). The patient was treated with doxycycline (100mg/twice daily). On the second day of treatment, he had no fever and reported decreases in headache and myalgia. At the end of doxycycline treatment for seven days, he was asymptomatic and with no cutaneous lesions. We repeated serology tests for spotted fever 30 days later, observing a drop in titration and negative results for the three antibodies: anti-Proteus OX-2 (less than 1/20), anti-Proteus OX-19 (1/80), and anti-Proteus OX-K (less than 1/80).

Figure 3
Hydropic degeneration of basal cells with subepidermal clefts, detachment of parts of the epidermis, individual and confluent necrosis of keratinocytes and accumulation of neutrophils, fibrin, and crusts. Dermis revealing superficial and perivascular inflammatory lymphomononuclear infiltrates (Hematoxylin & eosin, X200)

Spotted fever is a rickettsial disease that manifests itself as an acute, febrile infectious disease of varying severity.11 Parola P, Paddock CD, Socolovschi C, Labruna MB, Mediannikov O, Kernif T, et al. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev. 2013;26:657-702.,22 Blanton LS. Rickettsial infections in the tropics and in the traveler. Curr Opin Infect Dis. 2013;26:435-40 Human rickettsial diseases already described in Brazil can be classified into three groups: classical, atypical, and new or recently described. Classical rickettsioses common symptoms include high fever with sudden onset and frequent exanthema. Atypical rickettsioses feature a poorly defined clinical picture and may go unnoticed, without clinical or laboratory diagnosis. The third group, new rickettsiosis, includes vesicular rickettsial infection (rickettsialpox), Debonel/Tibola, perimiocarditis, and rickettsia felis.33 Galvão MAM, Silva LJ, Nascimento EMM, Calic SB, Sousa R, Bacellare F. Riquetsioses no Brasil e Portugal: ocorrência, distribuição e diagnóstico. Rev Saúde Pública. 2005;39:850-6.

Its diagnosis can be considered a challenge because many physicians are not familiar with the nonspecific symptoms of the early stages of the disease. The Weil-Felix method is easy to implement and inexpensive. The reaction detects antibodies in the serum of patients, which react with different strains or species of Proteus. Each species has antigenic epitopes similar to the lipopolysaccharides of the rickettsia membranes of the different groups. Its positivity indicates only the presence of an infection caused by rickettsia. The gold standard for the diagnosis of rickettsial disease is indirect immunofluorescence, which uses species-specific rickettsia antigens.44 Paris DH, Dumler JS. State of the art of diagnosis of rickettsial diseases: the use of blood specimens for diagnosis of scrub typhus, spotted fever group rickettsiosis, and murine typhus. Curr Opin Infect Dis. 2016;29:433-9.,55 Couto DV, Medeiros MZ, Hans Filho G, Lima AM, Barbosa AB, Vicari CF. Brazilian spotted fever: the importance of dermatological signs for early diagnosis. An Bras Dermatol. 2015;90:248-50.

This report may represent a description of a rickettsial disease not observed in Brazil to date: vesicular rickettsial disease. Characterized as a benign disease that manifests itself about a week after the bite of a parasitic mite of the mouse Mus musculus, the disease reveals a reddish and painless papule at the inoculation site, which becomes vesicular, associated with sudden fever with tremors, accompanied or not by vesicular exanthema similar to that of varicella.11 Parola P, Paddock CD, Socolovschi C, Labruna MB, Mediannikov O, Kernif T, et al. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev. 2013;26:657-702.,33 Galvão MAM, Silva LJ, Nascimento EMM, Calic SB, Sousa R, Bacellare F. Riquetsioses no Brasil e Portugal: ocorrência, distribuição e diagnóstico. Rev Saúde Pública. 2005;39:850-6.,44 Paris DH, Dumler JS. State of the art of diagnosis of rickettsial diseases: the use of blood specimens for diagnosis of scrub typhus, spotted fever group rickettsiosis, and murine typhus. Curr Opin Infect Dis. 2016;29:433-9.

Perceptions of the importance of diseases caused by rickettsia in public health has been increasing. Its early diagnosis is fundamental and decisive to avoid therapy delays. The authors emphasize that clinical evaluation is still the fastest and most precious diagnostic methods and highlight the importance of a dermatologist in the hospital environment.

  • *
    Work performed at Hospital São Francisco - Ribeirão Preto (SP), Brazil
  • Financial support: None.

REFERENCES

  • 1
    Parola P, Paddock CD, Socolovschi C, Labruna MB, Mediannikov O, Kernif T, et al. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev. 2013;26:657-702.
  • 2
    Blanton LS. Rickettsial infections in the tropics and in the traveler. Curr Opin Infect Dis. 2013;26:435-40
  • 3
    Galvão MAM, Silva LJ, Nascimento EMM, Calic SB, Sousa R, Bacellare F. Riquetsioses no Brasil e Portugal: ocorrência, distribuição e diagnóstico. Rev Saúde Pública. 2005;39:850-6.
  • 4
    Paris DH, Dumler JS. State of the art of diagnosis of rickettsial diseases: the use of blood specimens for diagnosis of scrub typhus, spotted fever group rickettsiosis, and murine typhus. Curr Opin Infect Dis. 2016;29:433-9.
  • 5
    Couto DV, Medeiros MZ, Hans Filho G, Lima AM, Barbosa AB, Vicari CF. Brazilian spotted fever: the importance of dermatological signs for early diagnosis. An Bras Dermatol. 2015;90:248-50.

Publication Dates

  • Publication in this collection
    Sep-Oct 2017

History

  • Received
    13 Sept 2016
  • Accepted
    18 Feb 2017
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