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Memory of an exotic holiday

  • Evelyne Franon
    Affiliations
    Medical Office, 9, rue Jean Sans Peur, Dijon, France
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  • Patrick Manckoundia
    Correspondence
    Corresponding author at: Service de Médecine Interne Gériatrie, Hôpital de Champmaillot CHU BP 87 909, 2, rue Jules Violle, F21079 Dijon Cedex, France. Tel.: +33 3 80 29 39 70; fax: +33 3 80 29 36 21.
    Affiliations
    Department of Geriatrics and Internal Medicine, Champmaillot Hospital, University Hospital, Dijon, France

    INSERM/U1093 Motricity-Plasticity, University of Burgundy, Dijon, France
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      Highlights

      • African Rickettsiosis is an endemic zoonosis in Africa and is transmitted by ticks.
      • Bites are usually painless and inconspicuous; the incubation period is 5 to 7 days.
      • The clinical features associate flu-like syndrome and skin lesions.
      • Serological tests become positive after 2 or 3 weeks of evolution.
      • In most cases, the spontaneous prognosis (without antibiotic therapy) is favorable.

      1. Indication

      A 66-year-old man with no particular medical history and back from a 10-day trip to South Africa, consulted for headache, myalgia, odynophagia and low-grade fever (38°), which had lasted for 3 days. The clinical examination revealed several escharotic skin lesions on the anterior left groin (Fig. 1a ) and right ankle (Fig. 1b), which had appeared the day before, without pain or itching. The lesions were surrounded by several erythematous papules. Biological tests showed leukopenia at 3400 cells/mm3 (normal 4000–10,800) with neutropenia at 1300 cells/mm3 (normal 1800–6800), and an increase in aspartate aminotransferase at 199 IU/L (normal 17–59) and alanine aminotransferase at 185 IU/L (normal 21–72).
      Figure thumbnail gr1
      Fig. 1Skin lesions of African Rickettsiosis on the anterior left groin (a) and the right ankle (b).
      What is the diagnosis?

      2. Diagnosis

      African Rickettsiosis was suspected and was confirmed by polymerase chain reaction on an eschar biopsy, despite negative serology.
      African Rickettsiosis is a zoonosis caused by Rickettsia Africae, an intracellular bacterium, and transmitted by Amblyomma hebraeum (ticks) [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ]. Clustered cases are frequent. In addition, multiple bites are frequently found in the same person; the bites are usually painless and inconspicuous. African Rickettsiosis is an endemic disease in Africa [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ]. It has also been identified in the French West Indies, Reunion and Oceania [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ].
      The incubation period for African Rickettsiosis is between 5 and 7 days before the onset of flu-like syndrome associated with skin lesions [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ]. The lesions may appear as inoculation eschars which can be associated with a maculopapular rash [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ]. Other common clinical features include regional lymphadenopathies [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ]. Diagnostic confirmation is based on a polymerase chain reaction swab of an inoculation eschar [
      • Solary J.
      • Socolovschi C.
      • Aubry C.
      • Brouqui P.
      • Raoult D.
      • Parola P.
      Detection of Rickettsia sibirica mongolitimonae by using cutaneous swab samples and quantitative PCR.
      ], which must be performed before antibiotic therapy. Serological tests become positive after 2 or 3 weeks of evolution [
      • Solary J.
      • Socolovschi C.
      • Aubry C.
      • Brouqui P.
      • Raoult D.
      • Parola P.
      Detection of Rickettsia sibirica mongolitimonae by using cutaneous swab samples and quantitative PCR.
      ]. Other biological tests frequently show lymphopenia, thrombocytopenia and hepatic cytolysis (mainly an increase in alanine aminotransferase). The treatment of African Rickettsiosis consists of Doxycycline, 200 mg daily for 7 days. However, in most cases, the spontaneous prognosis (without antibiotic therapy) is favorable [
      • Parola P.
      • Paddock C.D.
      • Socolovschi C.
      • Labruna M.B.
      • Mediannikov O.
      • Kemif T.
      • et al.
      Update on tick-borne rickettsioses around the world: a geographic approach.
      ].
      In these times of increased international travel, a skin eschar associated with fever should suggest rickettsial disease.

      Conflict of interest statement

      The authors have no conflicts of interest to declare.

      Acknowledgments

      The authors are grateful to Mr. Philip Bastable.

      References

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        • Socolovschi C.
        • Labruna M.B.
        • Mediannikov O.
        • Kemif T.
        • et al.
        Update on tick-borne rickettsioses around the world: a geographic approach.
        Clin Microbiol Rev. 2013; 26: 657-702
        • Solary J.
        • Socolovschi C.
        • Aubry C.
        • Brouqui P.
        • Raoult D.
        • Parola P.
        Detection of Rickettsia sibirica mongolitimonae by using cutaneous swab samples and quantitative PCR.
        Emerg Infect Dis. 2014; 20: 716-718