Underdiagnoses of Rickettsia in patients hospitalized with acute fever in Indonesia: observational study results

Reports of human rickettsial infection in Indonesia are limited. This study sought to characterize the epidemiology of human rickettsioses amongst patients hospitalized with fever at 8 tertiary hospitals in Indonesia. Acute and convalescent blood from 975 hospitalized non-dengue patients was tested...

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Bibliographic Details
Published in:	BMC infectious diseases Vol. 20; no. 1; pp. 364 - 12
Main Authors:	Lokida, Dewi, Hadi, Usman, Lau, Chuen-Yen, Kosasih, Herman, Liang, C Jason, Rusli, Musofa, Sudarmono, Pratiwi, Lukman, Nurhayati, Laras, Kanti, Asdie, Rizka Humardewayantie, Murniati, Dewi, Utama, I Made Susila, Mubin, Risna Halim, Karyana, Muhammad, Gasem, Muhammad Hussein, Alisjahbana, Bachti
Format:	Journal Article
Language:	English
Published:	England BioMed Central Ltd 24-05-2020 BioMed Central BMC
Subjects:	Acute Disease Adolescent Adult Aged Anorexia Antibodies Antibodies, Bacterial - blood Arthralgia Child Child, Preschool Chills Clinical pathway Dengue - diagnosis Dengue fever Deoxyribonucleic acid Development and progression Diagnosis, Differential Differential diagnosis DNA Enzyme-Linked Immunosorbent Assay Epidemiology Etiology Female Fever Fever - diagnosis Fever - microbiology Genomes Genomics Headache Health aspects Hospitalization Hospitals Humans Immunoglobulin G Immunoglobulin G - blood Immunoglobulin M Indonesia Indonesia - epidemiology Infant Infections Infectious diseases Laboratories Leptospirosis Leptospirosis - diagnosis Lethargy Lung diseases Male Middle Aged Myalgia Nausea Observational studies Orientia tsutsugamushi - immunology Pain Pathogens Patient education Plasma Public policy Retrospective Studies Rickettsia Rickettsia Infections - diagnosis Rickettsia Infections - epidemiology Rickettsia Infections - microbiology Rickettsia rickettsii - immunology Rickettsia typhi - immunology Rickettsioses Salmonella Scrub Typhus - diagnosis Sepsis Seroconversion Signs and symptoms Typhoid Typhoid Fever - diagnosis Typhus Urinary tract infections Vector-borne diseases Viral diseases Vomiting Waterborne diseases Young Adult Indonesia Asia Clinical pathway Rickettsioses Indonesia
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Summary:	Reports of human rickettsial infection in Indonesia are limited. This study sought to characterize the epidemiology of human rickettsioses amongst patients hospitalized with fever at 8 tertiary hospitals in Indonesia. Acute and convalescent blood from 975 hospitalized non-dengue patients was tested for Rickettsia IgM and IgG by ELISA. Specimens from cases with seroconversion or increasing IgM and/or IgG titers were tested for Rickettsia IgM and IgG by IFA and Rickettsia genomes using primers for Rickettsia (R.) sp, R. typhi, and Orientia tsutsugamushi. Testing was performed retrospectively on stored specimens; results did not inform patient management. R. typhi, R. rickettsii, and O. tsutsugamushi IgG antibodies were identified in 269/872 (30.8%), 36/634 (5.7%), and 19/504 (3.8%) of samples, respectively. For the 103/975 (10.6%) non-dengue patients diagnosed with acute rickettsial infection, presenting symptoms included nausea (72%), headache (69%), vomiting (43%), lethargy (33%), anorexia (32%), arthralgia (30%), myalgia (28%), chills (28%), epigastric pain (28%), and rash (17%). No acute rickettsioses cases were suspected during hospitalization. Discharge diagnoses included typhoid fever (44), dengue fever (20), respiratory infections (7), leptospirosis (6), unknown fever (6), sepsis (5), hepatobiliary infections (3), UTI (3), and others (9). Fatalities occurred in 7 (6.8%) patients, mostly with co-morbidities. Rickettsial infections are consistently misdiagnosed, often as leptospirosis, dengue, or Salmonella typhi infection. Clinicians should include rickettsioses in their differential diagnosis of fever to guide empiric management; laboratories should support evaluation for rickettsial etiologies; and public policy should be implemented to reduce burden of disease.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 ObjectType-Undefined-3
ISSN:	1471-2334 1471-2334
DOI:	10.1186/s12879-020-05057-9