eMedicine Specialties > Dermatology > Bacterial Infections

Boutonneuse Fever: Differential Diagnoses & Workup

Author: Anna Zalewska, MD, PhD, Assistant Professor, Adjunct Professor, Department of Dermatology and Venereology, Medical University of Lodz, Poland
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Contributor Information and Disclosures

Updated: Jul 7, 2009

Differential Diagnoses

Chickenpox
Roseola Infantum
Cowpox Infection, Human
Scarlet Fever
Drug Eruptions
Schnitzler Syndrome
Lyme Disease
Viral Infections of the Mouth
Measles, Rubeola
Rocky Mountain Spotted Fever

Other Problems to Be Considered

Kawasaki disease15
Aseptic acute arthritis
Small-vessel vasculitis
Sepsis

Workup

Laboratory Studies

  • Suspicious rashes, including poxlike vesicles, may be caused by this organism.
    • Confirm the diagnosis of boutonneuse fever by using culture techniques instead of serologic tests.
    • Serologic confirmation of boutonneuse fever by immunofluorescent antibody test is possible only late in the infection.
  • Use culture of the organism as the reference standard for diagnosis; however, it is rarely performed during the acute phase of the disease, and it cannot be performed retrospectively unless samples were appropriately collected and stored (-70°C).
  • Basic laboratory tests for boutonneuse fever include the following:
    • Normochromic anemia
    • Leukopenia and lymphopenia
    • Thrombocytopenia (35% of patients)
    • Increased liver enzymes (60.5-64.8% of patients)
    • Increased creatinine values (29.7% of patients)
    • Urinalysis (blood in 35.9% of patients, and proteins in 56.4% of patients; asymptomatic)
    • Fibrinogen level (increased during acute phase)
    • Fibronectin level (decreased during acute phase)

Imaging Studies

  • In boutonneuse fever, a magnetic resonance study can demonstrate multifocal white matter disturbances if the central nervous system is involved.

Other Tests

  • Serology is usually a confirmatory method; however, these tests are useful only after an acute infection because antibodies can be detected late (even after 30 d post onset of symptoms).
  • On indirect immunofluorescence (IIF), the antibody titer in serum is increased only 2 weeks after the infection and at the peak level after 4 weeks. Afterward, the immunoglobulin M (IgM) level decreases and the IgG level remains high for several months. Titers of 1:64 or greater are diagnostic.16
  • The Weil-Felix reaction (agglutination type)
    • The result can become positive 40 days after the symptoms started, with OX19, OX2, and OXK strains of Proteus vulgaris antigens.
    • It is still used in clinical practice because of its convenience but has low sensitivity and specificity.
  • Isolation of R conorii by the centrifugation-shell vials technique
    • The result can become positive 14 days after inoculation.
    • Results can be obtained within 2-3 days of sample receipt.
  • IIF of R conorii in circulating endothelial cells (CEC) isolated from whole blood by using immunomagnetic beads can be performed.
    • This test is sensitive; 50% of results are positive.
    • Results can be obtained in 3 hours.
    • The initiation of the therapy has no influence on the results.
    • This test can be used in all routine laboratories.
  • Enzyme-linked immunosorbent assay (ELISA) techniques were developed to detect antibodies to lipopolysaccharides (LPS) of R conorii.
    • ELISA is a relatively simple and convenient way to serodiagnose boutonneuse fever with a single serum dilution.
    • It can be of use in laboratories that lack more sophisticated equipment (as needed for IIF).
  • Polymerase chain reaction (PCR) is not routinely used or universally available. Ergas et al reported early diagnosis using nested PCR.17

Procedures

  • Direct immunofluorescence of cutaneous biopsy specimens is diagnostic only during the acute phase of the disease.
    • It reveals endothelial hyperplasia, intraluminal thrombosis, and lymphocytic perivascular infiltrate.
    • The test is specific and sensitive if performed before the initiation of antimicrobial therapy and before the 10th day of the disease.
    • The test is not widely available because it is time consuming and requires an experienced pathologist with a well-equipped laboratory.
    • Results can be obtained within 2-3 days of sample receipt.

Staging

  • The first day of fever is recognized as the first day of the disease.
  • The acute stage is from the second to 14th day of the illness.
  • The convalescent stage starts from the 21st day.
  • The third week is the borderline period between the acute stage and the convalescent stage.

More on Boutonneuse Fever

Overview: Boutonneuse Fever
Differential Diagnoses & Workup: Boutonneuse Fever
Treatment & Medication: Boutonneuse Fever
Follow-up: Boutonneuse Fever
References
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References

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Further Reading

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Keywords

boutonneuse fever, BF, Mediterranean spotted fever, MSF, Carducci fever, Carducci's fever, tick typhus, South African tick typhus, Indian tick typhus, tick bite fever, rickettsial disease, Rickettsia conorii, R conorii

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Contributor Information and Disclosures

Author

Anna Zalewska, MD, PhD, Assistant Professor, Adjunct Professor, Department of Dermatology and Venereology, Medical University of Lodz, Poland
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Robin Travers, MD, Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians
Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Medical Dermatology Society, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Paul Krusinski, MD, Director of Dermatology, Professor, Department of Internal Medicine, Fletcher Allen Health Care, University of Vermont
Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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