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This study sought to characterize the epidemiology of human rickettsioses amongst patients hospitalized with fever at 8 tertiary hospitals in Indonesia.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Acute and convalescent blood from 975 hospitalized non-dengue patients was tested for\n                      <jats:italic>Rickettsia<\/jats:italic>\n                      IgM and IgG by ELISA. Specimens from cases with seroconversion or increasing IgM and\/or IgG titers were tested for\n                      <jats:italic>Rickettsia<\/jats:italic>\n                      IgM and IgG by IFA and\n                      <jats:italic>Rickettsia<\/jats:italic>\n                      genomes using primers for\n                      <jats:italic>Rickettsia (R.) sp<\/jats:italic>\n                      ,\n                      <jats:italic>R. typhi<\/jats:italic>\n                      , and\n                      <jats:italic>Orientia tsutsugamushi<\/jats:italic>\n                      . Testing was performed retrospectively on stored specimens; results did not inform patient management.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      <jats:italic>R. typhi, R. rickettsii<\/jats:italic>\n                      , and\n                      <jats:italic>O. tsutsugamushi<\/jats:italic>\n                      IgG antibodies were identified in 269\/872 (30.8%), 36\/634 (5.7%), and 19\/504 (3.8%) of samples, respectively. For the 103\/975 (10.6%) non-dengue patients diagnosed with acute rickettsial infection, presenting symptoms included nausea (72%), headache (69%), vomiting (43%), lethargy (33%), anorexia (32%), arthralgia (30%), myalgia (28%), chills (28%), epigastric pain (28%), and rash (17%). No acute rickettsioses cases were suspected during hospitalization. Discharge diagnoses included typhoid fever (44), dengue fever (20), respiratory infections (7), leptospirosis (6), unknown fever (6), sepsis (5), hepatobiliary infections (3), UTI (3), and others (9). Fatalities occurred in 7 (6.8%) patients, mostly with co-morbidities.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      Rickettsial infections are consistently misdiagnosed, often as leptospirosis, dengue, or\n                      <jats:italic>Salmonella typhi<\/jats:italic>\n                      infection. Clinicians should include rickettsioses in their differential diagnosis of fever to guide empiric management; laboratories should support evaluation for rickettsial etiologies; and public policy should be implemented to reduce burden of disease.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12879-020-05057-9","type":"journal-article","created":{"date-parts":[[2020,5,24]],"date-time":"2020-05-24T05:02:42Z","timestamp":1590296562000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":26,"title":["Underdiagnoses of Rickettsia in patients hospitalized with acute fever in Indonesia: observational study results"],"prefix":"10.1186","volume":"20","author":[{"given":"Dewi","family":"Lokida","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Usman","family":"Hadi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chuen-Yen","family":"Lau","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1095-3422","authenticated-orcid":false,"given":"Herman","family":"Kosasih","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"C. 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Vector Borne Zoonotic Dis. 2020;20(2):93\u20139.","journal-title":"Vector Borne Zoonotic Dis"}],"container-title":["BMC Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12879-020-05057-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12879-020-05057-9\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12879-020-05057-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,5,23]],"date-time":"2021-05-23T19:10:44Z","timestamp":1621797044000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcinfectdis.biomedcentral.com\/articles\/10.1186\/s12879-020-05057-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,5,24]]},"references-count":40,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2020,12]]}},"alternative-id":["5057"],"URL":"https:\/\/doi.org\/10.1186\/s12879-020-05057-9","relation":{"has-preprint":[{"id-type":"doi","id":"10.21203\/rs.2.22952\/v2","asserted-by":"object"},{"id-type":"doi","id":"10.21203\/rs.2.22952\/v1","asserted-by":"object"},{"id-type":"doi","id":"10.21203\/rs.2.22952\/v3","asserted-by":"object"}]},"ISSN":["1471-2334"],"issn-type":[{"value":"1471-2334","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,5,24]]},"assertion":[{"value":"2 February 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"28 April 2020","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 May 2020","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"All subjects provided written informed consent before study participation. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the IRBs of Faculty of Medicine, University of Indonesia\/ Dr. Cipto Mangunkusumo Hospital (451\/PT02.FK\/ETIK\/2012), Dr. Soetomo Hospital (192\/Panke.KKE\/VIII\/2012), and the National Institute of Health and Research and Development (NIHRD), Ministry of Health, Indonesia (KE.01.05\/EC\/407\/2012).","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"364"}}