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Japan: 84-yr-old Woman Beats Co-infection with Severe Fever with Thrombocytopenia Syndrome Virus and Rickettsia japonica after Tick Bite

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  • Japan: 84-yr-old Woman Beats Co-infection with Severe Fever with Thrombocytopenia Syndrome Virus and Rickettsia japonica after Tick Bite

    https://wwwnc.cdc.gov/eid/article/27/4/20-3610_article
    Fujikawa T, Yoshikawa T, Kurosu T, Shimojima M, Saijo M, Yokota K. Co-infection with Severe Fever with Thrombocytopenia Syndrome Virus and Rickettsia japonica after Tick Bite, Japan. Emerg Infect Dis. 2021;27(4):1247-1249. https://doi.org/10.3201/eid2704.203610

    Abstract

    Severe fever with thrombocytopenia syndrome was diagnosed in a febrile woman in Japan after a tick bite. However, Rickettsia japonica DNA was retrospectively detected in the eschar specimen, suggesting co-infection from the bite. Establishment of the severe fever with thrombocytopenia syndrome virus infection might have overpowered the R. japonica infection.

    Severe fever with thrombocytopenia syndrome (SFTS) is caused by SFTS virus (SFTSV), a novel phlebovirus in the family Bunyaviridae (1). It has been reported that SFTS is endemic to Japan (2). SFTS is classified as a viral hemorrhagic fever, and its case-fatality rate in Japan is ≈30% (3).
    Japanese spotted fever (JSF) is an acute tickborne rickettsiosis caused by Rickettsia japonica and is endemic to Japan (4). Most cases of SFTS in Japan have been reported in southwestern Japan, and the JSF-endemic area overlaps the areas to which SFTS is endemic. Because the Haemaphysalis longicornis tick is a vector for both SFTSV and R. japonica (4,5), co-infection events might occur in patients with SFTS or R. japonica infection.


    A woman 84 years of age was bitten on her lower right back by a tick while working in a field. She became febrile on day 1, experienced mild delirium on day 2, and visited the emergency department of Mitoyo General Hospital (Kanonji, Japan) on day 5, where she had low-grade fever but was alert and lucid. Physical examination revealed an eschar surrounded by exanthema on her lower right back (Figure). She had noticed the eschar on the day after the bite, and her family removed it. We observed no other skin exanthema on her body. Laboratory analysis revealed thrombocytopenia and leukocytopenia (Table). Serum chemistry analyses revealed elongation of the activated partial thromboplastin time and an increase in the D-dimer level, suggesting coagulopathy. Because increases in aspartate transaminase and blood urea nitrogen were noted, liver and renal functions might have been impaired transiently (Table).
    Because of the fever, thrombocytopenia, history of tick bite, and eschar with localized exanthema, we suspected JSF. The patient’s blood samples and the crust of the eschar were tested by PCR assays for R. japonica, Orientia tsutsugamushi, and SFTSV. The serum sample tested positive for SFTSV by a conventional 1-step reverse transcription PCR reported previously (6). R. japonica DNA was also detected in the eschar sample through the methods described previously (7), but it was not detected in serum samples. We empirically administered 100 mg of minocycline intravenously for 7 days, after which minocycline was administered orally every 12 hours for 3 days. Her symptoms resolved without complications by day 6, the second day of admission. After discharge from the hospital on day 12, outpatient follow-up was uneventful...
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