Abstract

An 81-year-old man was found unconscious in a bathtub by his wife after having taken a long bath. He was rescued by his wife and son, and they dressed him while calling for an ambulance. On arrival, he was in a shock state with convulsion. After exposing him, he was found to have multiple macular skin rashes with eschar with a red halo on his lower right abdomen. He was treated with anticonvulsant and massive infusion. He had had right lower abdominal skin lesions for more than two weeks, general fatigue and skin rash for one week, and a fever for four days before the arrival. A biochemical analysis of his blood on arrival indicated inflammation, hepatic, renal disturbance, and coagulopathy. As he had the triad of tick-mediated infectious diseases, he received minocycline. His general condition improved, and he regained his consciousness on day 6. On day 9, we obtained positive results for scrub typhus. Finally, he was discharged home. Physicians should perform a full body skin examination of patients with a coma or fever in order not to miss fatal diseases.

1. Introduction

A full body skin examination (FBSE) is routinely performed by a trained healthcare professional to search for any unusual or suspicious lesions or conditions on the skin surface in patients with trauma, burn, or a high risk of skin cancer. ^{1, 2, 3, 4} Internal diseases can also manifest as a myriad of skin dermatoses, ranging from single disorders, such as calciphylaxis, cryoglobulinemia, amyopathic dermatomyositis, and Raynaud phenomenon, to spectrum disorders, such as neutrophilic dermatoses and morphea. ^{5, 6, 7} Often, the skin manifestations of systemic disease are vague and nonspecific. Systemic manifestations can also be vague and nonspecific, such as the toxic erythema, which might follow a viral infection or drug eruption, although some skin manifestations are highly specific and define the illness, such as smallpox, varicella, measles, rubella, and Reiter disease. ⁸

Ticks a re blood-sucking arthropods that attach to the skin through oral devices, causing diverse initial cutaneous manifestations, and may also transmit serious infectious diseases, such as Japanese spotted fever, scrub typhus (ST), or severe fever with thrombocytopenia syndrome in Japan.⁹ ST, also known as tsutsugamushi disease, was initially endemic to the Asia-Pacific region but has now spread worldwide due to globalization, with 1 million cases reported each year. ¹⁰ The causative pathogen is Orientia tsutsugamushi, a Gram-negative obligate intracellular rickettsial bacterium that is transmitted to warm-blooded animals by bites of Leptotrombidium mite larvae (chiggers). ¹⁰ ST is initially characterized by an eschar with a red halo lacking subjective symptoms as the primary lesion, which may appear two to three days before the sudden onset of flu-like symptoms, such as a fever with chills, headache, backache, myalgia, profuse sweating, vomiting, and enlarged lymph nodes. ¹¹ A macular or maculopapular skin rash as the secondary lesions can develop within three to eight days after the onset of the fever. ST can still be easily misdiagnosed, however, and without accurate and timely antibiotic treatment, fatality can reach 30%.10 Thus, a rapid and accurate diagnostic method is vital to tackle the ST epidemic.

We herein report a successful case of treating ST following an initial ocular inspection using a FBSE, even though the case was misdiagnosed as one of near drowning.

2. Case Report

An 81-year-old healthy Japanese man, who lived in Eastern Shizuoka, Japan, was found unconscious in a bathtub by his wife after having taken a long bath. He was rescued by his wife and son, and they dressed him while calling for an ambulance. When emergency medical technicians checked him, he was in a deep coma state with shock. The initial report to our hospital for the accommodation request described an unconscious male patient with drowning.

During the 60 minutes of transportation, he showed generalized convulsion, and on arrival, he continued to show convulsion. After exposing him, he was found to have multiple macular skin rashes with eschar with a red halo on his lower right abdomen (Figure 1). His blood pressure and percutaneous saturated oxygen were unmeasurable, and his heart rate was 140 beats per minute. He was treated with anticonvulsant and massive infusion after securing a venous route.

The results of a venous blood gas analysis were as follows: pH, 7.32; PCO2, 43 mmHg; PO2, 17 mmHg; HCO3-, 21 mmol/L; base excess, -3.6 mmol/L; lactate, 5.6, mmol/L. An electrocardiogram and cardiac echo study were negative. After the arrival of his family, we obtained his history. He had hypertension. In addition, he had had right lower abdominal skin lesions without subjective symptoms, resulting in him not bothering to check with a doctor, for over two weeks before his arrival at our hospital. He had also had general fatigue and a skin rash for one week before the arrival. He had visited a local near hospital due to a fever four days before the arrival, where he underwent a polymerase chain reaction (PCR) examination for COVID-19, but the result was negative. His skin was not checked there. His hobby was going for walks, and he often entered grassy areas. According conferring with his family, they informed us that the patient did not wish to receive lifesaving treatment. Accordingly, we did not perform these measures.

Whole-body computed tomography showed swelling of the mediastinal lymph nodes and mild-grade consolidation in the bilateral dorsal lungs. The results of a biochemical analysis of the blood on arrival are shown in Table 1.

In brief, these findings indicated inflammation, hepatic and renal disturbance, and coagulopathy.

As he had the triad of tick-mediated infectious diseases after the initial FBSE, he received minocycline and γ-globulin, followed by ampicillin/sulbactam for suspicious aspiration and noradrenalin and hydrocortisone for septic shock. On day 2, his skin rash and eschar as well as blood samples were provided to a public health center to check for tick-mediated infectious diseases.

The time course of treatment and main results of the biochemical analysis of the blood after admission are shown in Figure 2.

His respiration, circulation, renal function, and coagulopathy improved after these treatments. His liver function temporarily deteriorated but then also improved. Head magnetic resonance imaging on day 4 for the evaluation of his prolonged unconscious state showed findings suggestive of several septic thromboses in his brain. On day 6, he regained consciousness and could stand near his bedside with assistance. On day 9, the public health center reported positive results for ST by PCR. After rehabilitation, he was discharged home with minor recent memory disturbance.

3. Discussion

The present study demonstrates the usefulness of an FBSE for diagnosing tick-mediated infectious diseases and the survival outcome with early appropriate treatments, even in the present case, which had an acute physiology and chronic health evaluation II score of 34 points and a mortality risk of 73%. ¹² The early diagnosis and treatment are essential for managing fatal tick-mediated infectious diseases. Important diagnostic clues of a specific skin lesion (eschar with a red halo) might be found at the head, back, axillar, or inguinal areas, so an FBSE is recommended by The Japanese Association for Infectious Diseases (https://www.kansensho.or.jp/ref/d41.html).

Aside from ST, skin lesions can be an important clue for determining the cause of fatal internal diseases, infectious diseases, or indirect signs of septicemia, including specific skin lesions that can be clues to the clinical diagnosis of internal diseases ^{13, 14}; specific skin lesion that can be clues to the clinical diagnosis of infectious virus diseases ^{15, 16}; skin lesions itself as the main focus of fatal infectious disease ¹⁷; signs of disseminated intravascular coagulation and coagulopathy ¹⁸; signs of direct vascular invasion and occlusion by bacteria or fungi ^{19, 20}; signs of immune vasculitis and immune complex formation due to a medication, infection, malignancy, underlying inflammatory disease, or primary systemic vasculitis ²⁰; signs of emboli from endocarditis ²⁰; and signs of the effects of toxins ²¹. To diagnose a disease correctly, not only a visual inspection of the skin lesions but also a histological analysis and a biochemical analysis (including PCR and/or culture) may be required, similar to the present case.

Complaining of skin lesions is common among patients who visit an emergency room ²². However, a misdiagnosis or overlooking important cutaneous manifestations due to a fatal internal disease can result in a fatal outcome. ¹⁴ Accordingly, physicians should perform an FBSE when treating patients with a fever or coma, similar to the present case.

4. Conclusion

The present study demonstrated the usefulness of an FBSE for diagnosing fatal tick-mediated infectious diseases. Physician should perform an FBSE for patients with a coma or fever in order not to miss fatal diseases.

Acknowledgements

This work was supported in part by a Grant-in-Aid for Special Research in Subsidies for ordinary expenses of private schools from The Promotion and Mutual Aid Corporation for Private Schools of Japan.

References