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Tubular acute lymphangitis caused by Rickettsia sibirica mongolitimonae
Linfangitis aguda tubular por Rickettsia sibirica mongolitimonae
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"506" "paginaFinal" => "507" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sonia Miguélez Ferreiro, David Navalpotro Rodríguez" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Sonia" "apellidos" => "Miguélez Ferreiro" "email" => array:1 [ 0 => "tormentabranca@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "David" "apellidos" => "Navalpotro Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias de Atención Primaria, Hospital General de Valencia, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Microbiología, Hospital General de Valencia, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Linfangitis aguda tubular por <span class="elsevierStyleItalic">Rickettsia sibirica mongolitimonae</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1176 "Ancho" => 800 "Tamanyo" => 83607 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Eschar with surrounding erythema on the right leg. Erythematous cord of trunk-like lymphangitis from the eschar to the knee.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute lymphangitis is an acute inflammatory process in healthy or anatomically altered lymphatic vessels in either immunocompetent or immunocompromised patients. It generally develops after inoculation of microorganisms into the lymphatic vessels through a skin defect or as a complication of a distal infection.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is commonly caused by <span class="elsevierStyleItalic">Streptococcus pyogenes</span> and <span class="elsevierStyleItalic">Staphylococcus aureus;</span> in immunocompromised patients, Gram-negative bacteria; <span class="elsevierStyleItalic">Pasteurella multocida</span> or <span class="elsevierStyleItalic">Spirillum minus</span> after dog, cat or rat bites. Less common culprits are mycobacteria, viruses, fungi, parasites, <span class="elsevierStyleItalic">Rickettsias</span> or non-infectious causes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Clinically speaking, acute lymphangitis may be: reticular, tubular, nodular, phlyctenular or necrotising.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report here a case of tubular acute lymphangitis caused by <span class="elsevierStyleItalic">Rickettsia sibirica mongolitimonae</span> in Valencia, Spain.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was a 59-year-old man with no relevant medical history who consulted in April 2019 with a four-day history of pre-syncope, general malaise, headache, arthralgia, myalgia and fever of 38.5<span class="elsevierStyleHsp" style=""></span>°C. Three days before the onset of his symptoms, he developed an erythematous papule on his right leg. In the previous 48<span class="elsevierStyleHsp" style=""></span>h it had become enlarged so, suspecting cellulitis, he was started on amoxicillin/clavulanic acid 500<span class="elsevierStyleHsp" style=""></span>mg/8<span class="elsevierStyleHsp" style=""></span>h. Despite the antibiotic, the lesion had worsened, spreading to the knee, and he had developed painful enlarged right inguinal lymph nodes.</p><p id="par0020" class="elsevierStylePara elsevierViewall">He stated that he had not travelled outside Valencia. He had been in the countryside in an area with pigeons, rabbits, cats and dogs.</p><p id="par0025" class="elsevierStylePara elsevierViewall">On physical examination, he was found to have a temperature of 37.6<span class="elsevierStyleHsp" style=""></span>°C, the lesions shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> and left inguinal lymphadenitis. He had no peripheral lesions or rashes. The only blood test finding was CRP 35<span class="elsevierStyleHsp" style=""></span>mg/l. Urinalysis and chest X-ray were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The appearance of the eschar raised the suspicion of rickettsiosis and he was started on treatment with oral doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h for five days. Within 48<span class="elsevierStyleHsp" style=""></span>h his temperature had returned to normal and the rest of the symptoms and lesions gradually disappeared.</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the aetiological diagnosis, serological chemiluminescence immunoassay (CLIA) (Vircell, Granada, Spain) was performed for <span class="elsevierStyleItalic">Rickettsia conorii</span>, <span class="elsevierStyleItalic">C. burnetti</span> and <span class="elsevierStyleItalic">B. burgdorferi</span>, which were negative. A sample of exudate was obtained from the eschar, and Real-Time PCR (Fast Track Diagnostic, Luxembourg) detected <span class="elsevierStyleItalic">Rickettsia</span> spp DNA. Definitive species identification was obtained by molecular sequencing of a 525bp fragment of the <span class="elsevierStyleItalic">ompA gene</span>, which confirmed the presence of <span class="elsevierStyleItalic">Rickettsia sibirica mongolitimonae</span> (99.7% similarity with sequences deposited in GenBank®).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The serology was repeated at six weeks using CLIA and indirect immunofluorescence (IIF) (Vircell, Granada, Spain): IgG and IgM were positive against <span class="elsevierStyleItalic">Rickettsia conorii,</span> with evidence of cross reactions between <span class="elsevierStyleItalic">R. sibirica</span> and <span class="elsevierStyleItalic">R. conorii</span>.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Acute tubular, trunk- or branch-like lymphangitis affects the main superficial branches of the lymphatic vessels. An erythematous plaque appears and an indurated, erythematous, warm, palpable and painful sinuous tubular cord develops (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), extending proximally to the regional lymph nodes (lymphadenitis). It is usually accompanied by systemic symptoms: chills, fever, general malaise, headache, arthralgia, myalgia and nausea and/or vomiting. Laboratory tests may show leucocytosis, increased inflammatory parameters, and positive blood cultures.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It generally responds to empirical oral antibiotics. Infants and small children may require hospital admission in the case of significant systemic involvement or antibiotic resistance. Further exploratory tests are not usually necessary, unless there is a lack of response or atypical aetiology is suspected.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of lymphangitis, fever and an inoculation eschar should make us suspect lymphangitis-associated rickettsiosis (LAR)<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and start treatment with doxycycline. LAR do not have a specific clinical-aetiological correlation, and can be caused by different species of <span class="elsevierStyleItalic">Rickettsiae</span>.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> One of these is <span class="elsevierStyleItalic">R. sibirica mongolitimonae</span>, which is involved in less than half of the published cases of LAR.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> This is a rare type of rickettsiosis,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> which causes lymphangitis in approximately 35% of cases.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It tends to be transmitted in spring and summer by tick bites of the genera <span class="elsevierStyleItalic">Rhipicephalus</span> and <span class="elsevierStyleItalic">Hyalommas</span>.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We confirmed a case of lymphangitis due to <span class="elsevierStyleItalic">R. sibirica mongolitimonae</span> by PCR analysis of the eschar sample. This technique allows the definitive diagnosis of rickettsiosis with precision, speed and high sensitivity and specificity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Serology requires 2–3 weeks for seroconversion and shows cross-reactions, as in our case. The existence of cross reactions means that <span class="elsevierStyleItalic">R. sibirica mongolitimonae</span> is probably underdiagnosed, not only as a cause of LAR, but also of other types of rickettsiosis, as the microbiological diagnosis is based mainly on serology, and in many cases it is only performed against <span class="elsevierStyleItalic">R. conorii</span>.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Miguélez Ferreiro S, Navalpotro Rodríguez D. Linfangitis aguda tubular por <span class="elsevierStyleItalic">Rickettsia sibirica mongolitimonae</span>. Enferm Infecc Microbiol Clin. 2020;38:506–507.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1176 "Ancho" => 800 "Tamanyo" => 83607 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Eschar with surrounding erythema on the right leg. Erythematous cord of trunk-like lymphangitis from the eschar to the knee.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Protocolo diagnóstico y tratamiento de la enfermedad linfática aguda" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Galindo" 1 => "G. Móñux" 2 => "A. Martín" 3 => "F.J. Serrano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Medicine: Programa de Formación Médica Continuada Acreditado." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 31 | 2 | 33 |
| 2024 September | 62 | 5 | 67 |
| 2024 August | 59 | 6 | 65 |
| 2024 July | 42 | 9 | 51 |
| 2024 June | 36 | 5 | 41 |
| 2024 May | 29 | 5 | 34 |
| 2024 April | 40 | 0 | 40 |
| 2024 March | 67 | 3 | 70 |
| 2024 February | 87 | 2 | 89 |
| 2024 January | 70 | 5 | 75 |
| 2023 December | 89 | 5 | 94 |
| 2023 November | 103 | 7 | 110 |
| 2023 October | 114 | 8 | 122 |
| 2023 September | 71 | 4 | 75 |
| 2023 August | 66 | 7 | 73 |
| 2023 July | 90 | 14 | 104 |
| 2023 June | 77 | 4 | 81 |
| 2023 May | 84 | 3 | 87 |
| 2023 April | 81 | 2 | 83 |
| 2023 March | 100 | 3 | 103 |
| 2023 February | 70 | 7 | 77 |
| 2023 January | 65 | 4 | 69 |
| 2022 December | 89 | 4 | 93 |
| 2022 November | 57 | 6 | 63 |
| 2022 October | 59 | 12 | 71 |
| 2022 September | 60 | 10 | 70 |
| 2022 August | 40 | 6 | 46 |
| 2022 July | 49 | 7 | 56 |
| 2022 June | 49 | 14 | 63 |
| 2022 May | 37 | 9 | 46 |
| 2022 April | 40 | 15 | 55 |
| 2022 March | 64 | 8 | 72 |
| 2022 February | 46 | 3 | 49 |
| 2022 January | 64 | 4 | 68 |
| 2021 December | 34 | 6 | 40 |
| 2021 November | 34 | 9 | 43 |
| 2021 October | 71 | 14 | 85 |
| 2021 September | 50 | 3 | 53 |
| 2021 August | 46 | 6 | 52 |
| 2021 July | 12 | 6 | 18 |
| 2021 June | 8 | 0 | 8 |
| 2021 May | 1 | 0 | 1 |
| 2020 December | 1 | 2 | 3 |
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