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Travel Med Infect Dis. 2018 Mar 1. pii: S1477-8939(18)30017-6. doi: 10.1016/j.tmaid.2018.02.006. [Epub ahead of print]

Under-diagnosis of rickettsial disease in clinical practice: A systematic review.

Author information

1
Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands.
2
Leptospirosis Reference Center, Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
3
Medical Library, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
4
Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands. Electronic address: a.goorhuis@amc.uva.nl.

Abstract

BACKGROUND:

Rickettsial diseases present as acute febrile illnesses, sometimes with inoculation eschars.

METHODS:

We performed a systematic review of studies published between 1997 and 2017 to assess the underestimation of non-eschar rickettsial disease (NERD) relative to eschar rickettsial disease (ERD), as a cause of acute fever in patients with rickettsial diseases that commonly present with eschar(s): scrub typhus (ST), Mediterranean spotted fever (MSF), and African tick-bite fever. We compared ERD/NERD ratios according to study design: 'complete approach' studies, with testing performed in all patients with 'unspecified febrile illness'; versus 'clinical judgement' studies, with testing performed if patients presented with specific symptoms.

RESULTS:

In 'complete approach' studies, ERD/NERD ratios were significantly lower, suggesting a considerable under-diagnosis of NERD in 'clinical judgement' studies. Based on these results, we estimate that the diagnosis of rickettsial disease was missed in 66.5% of patients with ST, and in 57.9% of patients with MSF.

CONCLUSIONS:

Study design influences the reported eschar rates in ST and MSF significantly. NERD is likely to be a vastly underdiagnosed entity, and clinicians should consider and test for the disease more often.

PROSPERO REGISTRATION NUMBER:

CRD 42016053348.

KEYWORDS:

ERD/NERD ratio; Eschar; Eschar-related rickettsial disease (ERD); Non-eschar rickettsial disease (NERD); Rickettsioses

PMID:
29486240
DOI:
10.1016/j.tmaid.2018.02.006
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