ProMED-mail |

Published Date: 2012-05-01 23:08:48
Subject: PRO/MBDS> Undiagnosed illness - Viet Nam (06): Quang Ngai, rickettsia
Archive Number: 20120501.0991

UNDIAGNOSED ILLNESS - VIET NAM (06): QUANG NGAI, RICKETTSIA SUSP.
REQUEST FOR INFORMATION
******************************************************************************************

A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org

Date: Wed 25 Apr 2012
Source: Sai Gon Giai Phong Daily [edited]
http://www.saigon-gpdaily.com.vn/Health/2012/4/100887/

"Rickettsia" virus identified as cause of bizarre skin disease
-----------------------------------------
The Ministry of Health has so far identified the "Rickettsia" virus as
cause of the bizarre skin disease that has afflicted residents in the
central province of Quang Ngai, said a health official on [24 Apr 2012].
Pham Hong Phuong, director of the Department of Health in Quang Ngai
Province, said that medical experts have initially identified the
Risketsia virus as cause of the baffling skin disease in Ba Dien Commune
in Ba To District.

Of 26 blood samples taken of patients, 14 tested positive for Rickettsia
virus, with 30 per cent of the samples showing small and fragile red
blood cells that could have caused death in patients.

Till [24 Apr 2012], Quang Ngai Province had reported 172 cases of the
skin disease infection, 8 of whom had died at medical clinics and 11
having died at home. The disease begins with a rash on the hands and
feet, and progresses to affect and damage the liver and subsequently
damages other body organs.

As the disease develops unpredictably, the province leaders have decided
to equip the General Hospital with a blood filtering machine for
reducing fatalities. In addition, the province will support 5 per cent
of the health insurance expenses of patients affected with this
mysterious skin disease and being treated at the Quy Hoa National
Leprosy Dermatology Hospital.

As scheduled, the ministry will send a mission team to the province on
[24 Apr 2012] to continue finding out the causes of the disease.

Meantime, another strange disease occurred in Son Ha District of Quang
Ngai Province. Many people are beginning to suffer bruises in feet,
hands and face without any clear cause. The disease has hospitalised 19
students so far. Medical workers in district centres examined and gave
drugs to the students, but the cause of the disease is yet unknown. As
of now, it is suspected to be a skin disease caused by contact with
chemical herbicides.

--
Communicated by:
PRO/MBDS
<promed-mbds@promedmail.org>

[This newswire mentions that a total of 172 people have been affected by
an undiagnosed illess in Quang Ngai. Among those, 19 people died of this
strange disease. The newswire also reports that Viet Nam Ministry of
Health identified Rickettsia as the pathological agent of the strange
disease in Quang Ngai.

Rickettsia is a genus of non-motile, Gram-negative, non-spore forming,
highly pleomorphic bacteria. The classification of Rickettsia into 3
groups (spotted fever, typhus and scrub typhus) was based on serology.
This grouping has since been confirmed by DNA sequencing. All 3 of these
contain human pathogens.

Rickettsia species are carried by many ticks, fleas and lice, and
transmitted to human during feeding or by scratching infectious feces
into the skin. Inhaling dust contaminated with dried infected lice or
flea feces may also cause infections.

Rickettsia causes diseases in humans such as typhus, rickettsialpox,
Boutonneuse fever, African tick bite fever, Rocky Mountain spotted
fever, Flinders Island spotted fever and Queensland tick typhus
(Australian Tick Typhus).

Several other tick-borne species of Rickettsia, including _Rickettsia
rickettsii_, broadly grouped under the heading "Spotted Fever Group
Rickettsia (SFGR)" have been shown to cause human infections. The
initial symptoms of tick-borne SFGR infections generally include fever,
headache, fatigue and muscle aches. A maculopapular or petechial rash
may be present, and frequently a distinctive eschar (blackened or
crusted skin) may develop at the site of a tick bite. Multiple eschars
may be present if more than one tick bite occurred, see more at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5504a1.htm and
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/rickettsial-spotted-and-typhus-fevers-and-related-infections-anaplasmosis-and-ehrlichiosis.htm.

However, the article above does not say if a specific group of
Rickettsia is identified and how a differential diagnosis was made. In
addition, another cluster of skin disease was identified in 19 students
from Son Ha district of Quang Ngai province while the etiology remains
unclear.

Following comments are borrowed from bacterial disease moderator ML who
suggested other potential causes of this strange disease:

"At one point the lesions of the hands and feet are described as
"palmoplantar keratoderma", that is, an increased keratin layer on the
skin (hyperkeratosis) of the palms and soles; (see
http://emedicine.medscape.com/article/1108406-overview#aw2aab6b).
Palmoplantar keratoderma may be inherited or acquired. Conditions that
can lead to acquired palmoplantar keratoderma include inflammatory and
reactive dermatoses such as Reiter's syndrome (arthritis, conjunctivitis
or uveitis, and urethritis that follow dysentery or chlamydial or
gonococcal genital infection) and infections, such as those due to human
papillomavirus, _Treponema pallidum_ (the bacterium that causes
syphilis), _Mycobacterium tuberculosis_, and _Mycobacterium leprae_.

"Encrusted scabies may progress to hyperkeratotic and/or crusted lesions
on palmar surfaces. Painful keratotic plaques that involved the skin
surrounding the ears, the nose, and the soles in association with
polyarthritis has been described in patients with HIV infection
(http://www.nejm.org/doi/full/10.1056/NEJM200312113492425) and
keratoderma of the palms and soles has been seen in glucan-treated
patients with AIDS (http://www.ncbi.nlm.nih.gov/pubmed/2953313).

"Arsenic exposure can lead to multiple, irregular, warty keratotic
lesions on the palms and soles, typically decades after chronic arsenic
ingestion. Exposure to certain chemicals, namely chloracnegens, has been
reported to present as palmoplantar keratoderma (Patel S, Zirwas M,
English JC. Acquired palmoplantar keratoderma. Am J Clin Dermatol. 2007;
8(1): 1-11; abstract available at
http://www.ncbi.nlm.nih.gov/pubmed/17298101). Chloracnegens are
halogenated aromatic compounds, such as chlorinated dioxins and
polychlorinated biphenyls (PCBs). Chloracne is an acne-like eruption of
blackheads, cysts, and pustules on the face and neck, associated with
overexposure to halogenated aromatic compounds, such as chlorinated dioxins.

"The news articles say that exposure to a herbicide is suspected as the
cause of this outbreak, as the patients were affected soon after
spraying herbicides in cassava fields. The most toxic dioxin,
2,3,7,8-tetrachlorodibenzo-p-dioxin, became well known as a contaminant
of Agent Orange, a herbicide used in the Viet Nam war. Dioxins were
incriminated to have poisoned president Viktor Yushchenko of Ukraine in
2004."

PRO/MBDS would appreciate further information from knowledgeable sources
regarding this undiagnosed illness in Quang Ngai province, Viet Nam.

For a map of Viet Nam with provinces, see
http://upload.wikimedia.org/wikipedia/commons/f/f0/VietnameseProvincesMap.png.
For the interactive HealthMap/ProMED-mail map with direct links to other
outbreaks in Viet Nam and surrounding countries reported on ProMED-mail
and PRO/MBDS, see http://healthmap.org/r/1f3d. - Mod.QCN]

See Also