Cutaneous manifestations of spotted fever rickettsial infections in the Central Province of Sri Lanka: a descriptive study

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.

Figure 1. Tick bite marks found in patients, (A) a tick bite mark, ten days old, (B) a scarred tick bite mark, (C) a recent tick bite mark.

Figure 2. Fern leaf type skin necrosis in legs.

Figure 3. Erythematous or dusky red discrete skin rash in both upper and lower limbs involving hands and feet.

Figure 4. Acute arthritis of ankle joint and oedematous feet.

Figure 5. Scrotal swelling and gangrene of scrotal skin.

Figure 6. Vasculitic rash in toes and plantar surface of feet.

Figure 7. Cutaneous histopathology of maculopapular skin rash, (A) Black arrow- Exocytosis of extravasated lymphocytes.

White arrow – Focal swelling of endothelium (haematoxyline-eosin; original magnification ×200), (B) Arrows indicate the vacuolations in the basal cells of epidermis, (C) Black arrow – Ectatic upper dermal blood vessels. White arrow – extravasated red blood cells, (D) Black arrows – Lymphocytic infiltrates in perivascular spaces. White arrows – Focal swelling of endothelium and ectatic upper dermal blood vessels, (E) White arrow – Fibrinoid necrosis of a dermal vessel wall. Black arrow – Presence of fibrin thrombi. (hematoxyline-eosin; original magnification ×800). Scale bars = 50 µm.