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Nam HK, Min KD, Jo S, Cho SI. Association of Deforestation With Severe Fever With Thrombocytopenia Syndrome. J Infect Dis 2023; 228:1730-1738. [PMID: 37265042 PMCID: PMC10733741 DOI: 10.1093/infdis/jiad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 05/08/2023] [Accepted: 06/01/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Severe fever with thrombocytopenia syndrome (SFTS) virus was first isolated in China in 2009 and has since spread to several Asian countries. SFTS is closely related to environmental factors that accelerate vector growth. We evaluated the associations of SFTS and deforestation with environmental variables. METHODS For this observational study, we generated multiple Poisson models using national SFTS outbreak data (2013-2018) and official environmental data for Korea. We included established risk factors as variables. Deforestation was used as the main variable. All variables were analyzed according to their spatial characteristics using the R-INLA package. RESULTS SFTS cases increased over time and peaked in 2017, at 272, followed by a decrease in 2018. Disease mapping showed a high incidence of SFTS nationwide, with particular risks in Gangwon and Gyeonggi Provinces in the north, and Jeju in the south of South Korea. Deforestation was significantly associated with a higher risk of SFTS in the final model (relative risk, 1.751 [95% confidence interval, 1.125-2.743]). CONCLUSIONS SFTS outbreaks are associated with deforestation. Therefore, deforestation in Gyeonggi, Gangwon, and Jeju provinces of South Korea needs to be considered in vector-control strategies and active surveillance of SFTS occurrence.
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Affiliation(s)
- Hee-kyoung Nam
- Department of Public Health Science, Graduate School of Public Health, Seoul National University
| | - Kyung-Duk Min
- College of Veterinary Medicine, Chungbuk National University
| | - Suyoung Jo
- Department of Public Health Science, Graduate School of Public Health, Seoul National University
| | - Sung-il Cho
- Department of Public Health Science, Graduate School of Public Health, Seoul National University
- Institute of Health and Environment, Seoul National University, Republic of Korea
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Chatterjee S, Kim CM, Kim DM, Seo JW, Kim DY, Yun NR, Jung SI, Kim UJ, Kim SE, Kim HA, Kim ES, Hur J, Kim YK, Jeong HW, Heo JY, Jung DS, Lee H, Park SH, Kwak YG, Lee S, Chatterjee RP. Coinfection With Severe Fever With Thrombocytopenia Syndrome and Scrub Typhus in Korea. Open Forum Infect Dis 2023; 10:ofad377. [PMID: 37854108 PMCID: PMC10580145 DOI: 10.1093/ofid/ofad377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Indexed: 10/20/2023] Open
Abstract
Background Scrub typhus and severe fever with thrombocytopenia syndrome (SFTS) are the 2 most common tick-borne infectious diseases in Korea. Every year, an increasing number of cases are reported, which is a public health concern. Therefore, we aimed to investigate the prevalence of SFTS-scrub typhus coinfection in patients with SFTS. Methods Clinical samples were collected from 129 patients with SFTS. One-step reverse-transcription polymerase chain reaction (PCR) was performed to identify the SFTS virus (SFTSV), and real-time PCR followed by nested PCR was performed to detect the Orientia tsutsugamushi gene for scrub typhus. Phylogenetic analysis was conducted to confirm the evolutionary relationships among different species. Results Among 129 SFTS cases, 2 patients with SFTSV were positive for O. tsutsugamushi with a prevalence of coinfection of 1.6% (95% confidence interval, .001-.06). Phylogenetic analysis confirmed these as O. tsutsugamushi strain Boryong. Conclusions Our study found that 1.6% of patients were coinfected with SFTS and scrub typhus infection. We believe that this information will add a new dimension to clinical diagnosis, which should be considered for better public health management. Further research is needed to better understand the ecological transmission dynamics and geographical distribution of SFTSV and O. tsutsugamushi in endemic countries.
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Affiliation(s)
- Shilpa Chatterjee
- Department of Biomedical Science, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Choon-Me Kim
- Premedical Science, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Dong-Min Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Jun-Won Seo
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Da Young Kim
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Na-Ra Yun
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
| | - Sook In Jung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Uh Jin Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seong Eun Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyun ah Kim
- Division of Infectious Diseases, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Young Keun Kim
- Department of Internal Medicine, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea
| | - Hye Won Jeong
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Jung Yeon Heo
- Department of Infectious Diseases, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Dong Sik Jung
- Department of Internal Medicine, College of Medicine, Dong-A University, Busan, Republic of Korea
| | - Hyungdon Lee
- Department of Internal Medicine, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Republic of Korea
| | - Sun Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Yee Gyung Kwak
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Sujin Lee
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan, Republic of Korea
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Won EJ, Kim SH, Byeon KH, Jeon CH, Kang SJ, Park JH, Kee SJ, Choi HW. Under-diagnosis of vector-borne diseases among individuals suspected of having Scrub Typhus in South Korea. PLoS One 2023; 18:e0286631. [PMID: 37267407 DOI: 10.1371/journal.pone.0286631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/19/2023] [Indexed: 06/04/2023] Open
Abstract
Due to environmental and ecological changes and suitable habitats, the occurrence of vector-borne diseases is increasing. We investigated the seroprevalence of four major vector-borne pathogens in human patients with febrile illness who were clinically suspected of having Scrub Typhus (ST) caused by Orientia tsutsugamushi. A total of 187 samples (182 patient whole blood and sera samples, including 5 follow-up) were collected. Antibodies to Anaplasma phagocytophilum, Ehrlichia chaffeensis, Borrelia burgdorferi, and Bartonella henselae were tested by using indirect immunofluorescence assays. Molecular diagnoses were performed using real-time PCR. Of the 182 cases, 37 (20.3%) cases were designated as confirmed cases of ST, and the remaining 145 (79.7%) cases as other febrile diseases (OFDs). The seroprevalence of A. phagocytophilum, E. chaffeensis, B. burgdorferi, and B. henselae was 51.4% (19/37), 10.8% (4/37), 86.5% (32/37), and 10.8% (4/37) among the ST group, and 42.8% (62/145), 10.4% (19/145), 57.7% (105/145), and 15.9% (29/145) among the OFD group, respectively. There were no significant differences in the seroprevalence between the ST and the OFD groups. Considering the co-occurrence, 89.0% (162/182) had at least one antibody to tick-borne pathogens, 37.0% (60/162) were positive for two pathogens, 17.3% (28/162) for three pathogens, and 6.2% (10/162) for four pathogens. In real-time PCR, O. tsutsugamushi was positive in 16 cases [15 (40.5%) in ST group and 1 (2.2%) in OFD group], and the four other pathogens were negative in all cases except one confirmed as anaplasmosis. In evaluating the five follow-up samples, the appearance of new antibodies or an increase in the pre-existing antibody titers was detected. Our data highlighted that acute febrile illness and manifestations suggestive of a vector-borne infection must be recognized and further considered for coinfections in clinical practice and the laboratory.
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Affiliation(s)
- Eun Jeong Won
- Departments of Parasitology and Tropical Medicine, Chonnam National University Medical School, Hwasun, South Korea
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seong Hoon Kim
- Departments of Parasitology and Tropical Medicine, Chonnam National University Medical School, Hwasun, South Korea
| | - Kyeong Hwan Byeon
- Departments of Parasitology and Tropical Medicine, Chonnam National University Medical School, Hwasun, South Korea
| | - Chae-Hyeon Jeon
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Seung-Ji Kang
- Department of Infectious Disease, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
| | - Joo-Heon Park
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Seung-Jung Kee
- Department of Laboratory Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyun-Woo Choi
- Department of Laboratory Medicine, Chonnam National University Bitgoeul Hospital, Gwangju, South Korea
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Jang WS, Lim DH, Choe YL, Nam J, Moon KC, Kim C, Choi M, Park I, Park DW, Lim CS. Developing a multiplex loop-mediated isothermal amplification assay (LAMP) to determine severe fever with thrombocytopenia syndrome (SFTS) and scrub typhus. PLoS One 2022; 17:e0262302. [PMID: 35171943 DOI: 10.1371/journal.pone.0262302] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022] Open
Abstract
Severe fever with thrombocytopenia syndrome (SFTS) and scrub typhus are endemic zoonotic diseases that pose significant public health threats in East Asia. As these two diseases share common clinical features, as well as overlapping disease regions, it is difficult to differentiate between SFTS and scrub typhus. A multiplex reverse-transcription loop‑mediated isothermal amplification (RT-LAMP) assay was developed to detect large segments and GroES genes for SFTS virus (SFTSV) and Orientia tsutsugamushi (OT). The performance of the RT-LAMP assay was compared and evaluated with those of commercial PowerChek™ SFTSV real-time PCR and LiliF™ TSUTSU nested PCR for 23 SFTS and 12 scrub typhus clinical samples, respectively. The multiplex SFTSV/OT/Internal control (IC) RT-LAMP assay showed comparable sensitivity (91.3%) with that of commercial PowerChek™ SFTSV Real-time PCR (95.6%) and higher sensitivity (91.6%) than that of LiliF™ TSUTSU nested PCR (75%). In addition, the multiplex SFTSV/OT RT-LAMP assay showed 100% specificity and no cross-reactivity for blood from uninfected healthy patients and samples from patients infected with other fever viruses. Thus, the multiplex SFTSV/OT/IC RT-LAMP assay could serve as a useful point-of-care molecular diagnostic test for SFTS and scrub typhus.
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Win AM, Nguyen YTH, Kim Y, Ha NY, Kang JG, Kim H, San B, Kyaw O, Htike WW, Choi DO, Lee KH, Cho NH. Genotypic Heterogeneity of Orientia tsutsugamushi in Scrub Typhus Patients and Thrombocytopenia Syndrome Co-infection, Myanmar. Emerg Infect Dis 2021; 26:1878-1881. [PMID: 32687023 PMCID: PMC7392420 DOI: 10.3201/eid2608.200135] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Serologic and molecular surveillance of serum collected from 152 suspected scrub typhus patients in Myanmar revealed Orientia tsutsugamushi of genotypic heterogeneity. In addition, potential co-infection with severe fever with thrombocytopenia syndrome virus was observed in 5 (3.3%) patients. Both scrub typhus and severe fever with thrombocytopenia syndrome are endemic in Myanmar.
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Ra SH, Kim MJ, Kim MC, Park SY, Park SY, Chong YP, Lee SO, Choi SH, Kim YS, Lee KH, Kim SH, Kee SH. Kinetics of Serological Response in Patients with Severe Fever with Thrombocytopenia Syndrome. Viruses 2020; 13:v13010006. [PMID: 33375753 PMCID: PMC7823500 DOI: 10.3390/v13010006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 11/17/2022] Open
Abstract
Severe fever with thrombocytopenia syndrome (SFTS) is caused by SFTS virus (SFTSV). We investigated the detailed kinetics of serologic response in patients with SFTS. Twenty-eight patients aged ≥18 years were enrolled between July 2015 and October 2018. SFTS was confirmed by detecting SFTSV RNA in their plasma using reverse transcription polymerase chain reaction. SFTSV-specific IgG and IgM were measured using immunofluorescence assay (IFA) and enzyme-linked immunosorbent assay (ELISA). We found that SFTSV-specific IgG was detected at days 5–9 after symptom onset, and its titer was rising during the course of disease. SFTSV-specific IgM titer peaked at around week 2–3 from symptom onset. The SFTSV-specific seropositive rates for days 5–9, 10–14, 15–19, and 20–24 from symptom onset using IFA and ELISA were 63%, 76%, 90%, and 100%, and 58%, 86%, 100%, and 100%, respectively, for IgG, whereas they were 32%, 62%, 80%, and 100%, and 53%, 62%, 70%, and 100%, respectively, for IgM. The delayed IgM response could be attributed to the low sensitivity of SFTSV-specific IgM IFA or ELISA and/or impaired immune responses. The IgM test using IFA or ELISA that we used in this study is, therefore, insufficient for the early diagnosis of SFTS.
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Affiliation(s)
- Sang Hyun Ra
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Min-Chul Kim
- Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Dongjak-gu, Seoul 06973, Korea;
| | - Se Yoon Park
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University College of Medicine, Yongsan-gu, Seoul 04401, Korea;
| | - Seong Yeon Park
- Department of Infectious Diseases, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Ilsandong-gu, Goyang-si 10326, Korea;
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
| | - Keun Hwa Lee
- Department of Microbiology, Hanyang University College of Medicine, Seongdong-gu, Seoul 04763, Korea
- Correspondence: (K.H.L.); (S.-H.K.)
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 05505, Korea; (S.H.R.); (M.J.K.); (Y.P.C.); (S.-O.L.); (S.-H.C.); (Y.S.K.)
- Correspondence: (K.H.L.); (S.-H.K.)
| | - Sun-Ho Kee
- Department of Microbiology, Korea University College of Medicine, Seongbuk-gu, Seoul 02841, Korea;
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Abstract
Severe fever with thrombocytopenia syndrome virus (SFTSV) is a novel bunyavirus. Since 2007, SFTS disease has been reported in China with high fatality rate up to 30%, which drew high attention from Centre for Disease Control and Prevention and government. SFTSV is endemic in the centra l and eastern China, Korea and Japan. There also have been similar cases reported in Vietnam. The number of SFTSV infection cases has a steady growth in these years. As SFTSV could transmitted from person to person, it will expose the public to infectious risk. In 2018 annual review of the Blueprint list of priority diseases, World Health Organisation has listed SFTSV infection as prioritised diseases for research and development in emergency contexts. However, the pathogenesis of SFTSV remains largely unclear. Currently, there are no specific therapeutics or vaccines to combat infections of SFTSV. This review discusses recent findings of epidemiology, transmission pathway, pathogenesis and treatments of SFTS disease.
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Affiliation(s)
- Jing Li
- NHC Key Laboratory of Carcinogenesis, Department of Hematology, Xiangya Hospital, Central South University, Changsha, China.,Department of Microbiology, School of Basic Medical Sciences, Central South University, Changsha, China.,China-Africa Research Center of Infectious Diseases, Central South University, Changsha, China
| | - Shen Li
- NHC Key Laboratory of Carcinogenesis, Department of Hematology, Xiangya Hospital, Central South University, Changsha, China.,Department of Microbiology, School of Basic Medical Sciences, Central South University, Changsha, China.,China-Africa Research Center of Infectious Diseases, Central South University, Changsha, China
| | - Li Yang
- NHC Key Laboratory of Carcinogenesis, Department of Hematology, Xiangya Hospital, Central South University, Changsha, China.,Department of Microbiology, School of Basic Medical Sciences, Central South University, Changsha, China.,China-Africa Research Center of Infectious Diseases, Central South University, Changsha, China
| | - Pengfei Cao
- NHC Key Laboratory of Carcinogenesis, Department of Hematology, Xiangya Hospital, Central South University, Changsha, China.,Department of Microbiology, School of Basic Medical Sciences, Central South University, Changsha, China.,China-Africa Research Center of Infectious Diseases, Central South University, Changsha, China
| | - Jianhong Lu
- NHC Key Laboratory of Carcinogenesis, Department of Hematology, Xiangya Hospital, Central South University, Changsha, China.,Department of Microbiology, School of Basic Medical Sciences, Central South University, Changsha, China.,China-Africa Research Center of Infectious Diseases, Central South University, Changsha, China
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Kawaguchi T, Umekita K, Yamanaka A, Hara S, Yamaguchi T, Inoue E, Okayama A. Impact of C-Reactive Protein Levels on Differentiating of Severe Fever With Thrombocytopenia Syndrome From Japanese Spotted Fever. Open Forum Infect Dis 2020; 7:ofaa473. [PMID: 33204759 PMCID: PMC7651123 DOI: 10.1093/ofid/ofaa473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022] Open
Abstract
Background Severe fever with thrombocytopenia syndrome (SFTS) is an emerging viral hemorrhagic fever in China, Korea, and Japan. Japanese spotted fever (JSF), which belongs to spotted fever group rickettsioses, is also endemic to Western Japan. Patients with SFTS and those with JSF display many of the same clinical manifestations. Sudden fever, rash, tick bite, and neurological and gastrointestinal symptoms may be seen in both infections, but the frequency and severity of each disease have not been compared and studied. Because laboratory confirmation of pathogens takes time, it is important to predict diagnosis of SFTS vs JSF based on the features of the clinical characteristics at the initial presentation, particularly in primary care settings. Methods We conducted a case series review at 4 medical facilities in Miyazaki, Japan. Based on the medical records, clinical and laboratory characteristics were compared between patients with SFTS and those with JSF. Results Eighty-one patients were enrolled in this study, including 41 with SFTS and 40 with JSF. The absence of rash (P < .001), leukopenia (P < .001), and normal C-reactive protein (CRP) levels (P < .001) were the variables distinguishing SFTS from JSF. Normal CRP levels (≤1.0 mg/dL) had a 95% sensitivity (84%–99%) and 97% specificity (87%–100%) for SFTS, with a positive likelihood ratio of 37.1 (5.35–257). Conclusions Normal serum CRP levels were shown to differentiate SFTS from JSF with a very high probability.
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Affiliation(s)
- Takeshi Kawaguchi
- Department of Rheumatology, Infectious Diseases, and Laboratory Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kunihiko Umekita
- Department of Rheumatology, Infectious Diseases, and Laboratory Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Atsushi Yamanaka
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Seiichiro Hara
- Department of Internal Medicine, Miyazaki Prefectural Nichinan Hospital, Miyazaki, Japan
| | - Tetsuro Yamaguchi
- Department of Internal Medicine, Miyazaki Prefectural Nobeoka Hospital, Miyazaki, Japan
| | - Eisuke Inoue
- Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Akihiko Okayama
- Department of Rheumatology, Infectious Diseases, and Laboratory Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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