Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center (AMC), University of Amsterdam (UvA), Amsterdam, The Netherlands.
Leptospirosis Reference Center, Department of Medical Microbiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Travel Med Infect Dis. 2018 Nov-Dec;26:7-15. doi: 10.1016/j.tmaid.2018.02.006. Epub 2018 Mar 2.
Rickettsial diseases present as acute febrile illnesses, sometimes with inoculation eschars.
We performed a systematic review of studies published between 1997 and 2017 to assess the underestimation of non-eschar rickettsial disease (NERD) relative to eschar rickettsial disease (ERD), as a cause of acute fever in patients with rickettsial diseases that commonly present with eschar(s): scrub typhus (ST), Mediterranean spotted fever (MSF), and African tick-bite fever. We compared ERD/NERD ratios according to study design: 'complete approach' studies, with testing performed in all patients with 'unspecified febrile illness'; versus 'clinical judgement' studies, with testing performed if patients presented with specific symptoms.
In 'complete approach' studies, ERD/NERD ratios were significantly lower, suggesting a considerable under-diagnosis of NERD in 'clinical judgement' studies. Based on these results, we estimate that the diagnosis of rickettsial disease was missed in 66.5% of patients with ST, and in 57.9% of patients with MSF.
Study design influences the reported eschar rates in ST and MSF significantly. NERD is likely to be a vastly underdiagnosed entity, and clinicians should consider and test for the disease more often.
CRD 42016053348.
立克次体病表现为急性发热性疾病，有时伴有接种性焦痂。
我们对 1997 年至 2017 年间发表的研究进行了系统评价，以评估非焦痂性立克次体病（NERD）相对于焦痂性立克次体病（ERD）的低估程度，后者是常见有焦痂（恙虫病、地中海斑疹热和非洲蜱咬热）的立克次体病患者急性发热的原因。我们根据研究设计比较了 ERD/NERD 比值：“全面方法”研究，对所有“未特指的发热性疾病”患者进行检测；与“临床判断”研究相比，对有特定症状的患者进行检测。
在“全面方法”研究中，ERD/NERD 比值显著降低，表明“临床判断”研究中对 NERD 的诊断明显不足。根据这些结果，我们估计恙虫病患者中有 66.5%、地中海斑疹热患者中有 57.9%漏诊了立克次体病。
研究设计对立克次体病的焦痂发生率有显著影响。NERD 可能是一种严重被漏诊的疾病，临床医生应更经常地考虑并检测这种疾病。
PROSPERO 注册号：CRD 42016053348。
