{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T19:33:49Z","timestamp":1779910429981,"version":"3.53.1"},"update-to":[{"DOI":"10.1371\/journal.pntd.0014377","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T00:00:00Z","timestamp":1779408000000}}],"reference-count":16,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T00:00:00Z","timestamp":1779235200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Kameda Medical Center"},{"DOI":"10.13039\/100009619","name":"Japan Agency for Medical Research and Development","doi-asserted-by":"publisher","award":["JP21fk0108614"],"award-info":[{"award-number":["JP21fk0108614"]}],"id":[{"id":"10.13039\/100009619","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Early diagnosis of scrub typhus and Japanese spotted fever remains challenging because initial manifestations are often nonspecific. In endemic areas, nearly 30% of patients were not correctly diagnosed at the first visit to a participating site. Previous studies have mainly treated rash and eschar as present-or-absent findings. We examined how rash and eschar came to clinical attention in patients correctly diagnosed at the first visit to a participating site and in those diagnosed later.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methodology\/principal findings<\/jats:title>\n                    <jats:p>We analyzed 217 patients with scrub typhus or Japanese spotted fever from three healthcare facilities in an endemic region of Japan. Because first-visit documentation was incomplete in many delayed-diagnosis cases, recognition-pattern variables were abstracted at the time the correct diagnosis was established. Among these patients, 156 (71.9%) were correctly diagnosed at the first visit to a participating site and 61 (28.1%) were diagnosed after one or more subsequent visits. In multivariable analysis, correct first-visit diagnosis was associated with rash reported as a chief complaint (adjusted odds ratio [aOR] 4.95, 95% confidence interval [CI] 2.07\u201311.84), rash elicited during history taking (aOR 5.86, 95% CI 2.80\u201312.27), eschar identified on physical examination (aOR 2.80, 95% CI 1.19\u20136.58), and eschar elicited during history taking, which was exclusively observed among patients diagnosed at the first visit to a participating site. Age 75 years or older was associated with lower odds of correct first-visit diagnosis (aOR 0.40, 95% CI 0.21\u20130.75).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Conclusions\/significance<\/jats:title>\n                    <jats:p>In endemic settings, patients correctly diagnosed at the first visit to a participating site more often had rash and eschar brought to clinical attention in specific ways. Directed inquiry about skin symptoms and careful examination for eschar may help recognition in routine care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pntd.0014377","type":"journal-article","created":{"date-parts":[[2026,5,20]],"date-time":"2026-05-20T17:39:25Z","timestamp":1779298765000},"page":"e0014377","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["How rash and eschar came to clinical attention in scrub typhus and Japanese spotted fever"],"prefix":"10.1371","volume":"20","author":[{"given":"Eiichiro","family":"Sando","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4503-5579","authenticated-orcid":true,"given":"Ikkoh","family":"Yasuda","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,5,20]]},"reference":[{"key":"pntd.0014377.ref001","unstructured":"Japan Institute for Health Security, Japan. Scrub typhus and Japanese spotted fever in Japan 2007-2016. 2017. Available from: https:\/\/id-info.jihs.go.jp\/niid\/en\/iasr\/7342-448te.html"},{"issue":"6","key":"pntd.0014377.ref002","doi-asserted-by":"crossref","first-page":"1386","DOI":"10.4269\/ajtmh.18-0258","article-title":"Case Report: Concurrent Sympatric Scrub Typhus and Japanese Spotted Fever in Japan","volume":"99","author":"E Sando","year":"2018","journal-title":"Am J Trop Med Hyg"},{"issue":"6","key":"pntd.0014377.ref003","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pntd.0011427","article-title":"Scrub typhus, a salient threat: Needs attention","volume":"17","author":"K Zaman","year":"2023","journal-title":"PLoS Negl Trop Dis"},{"issue":"2","key":"pntd.0014377.ref004","doi-asserted-by":"crossref","first-page":"63","DOI":"10.7883\/yoken.JJID.2024.216","article-title":"Clinical Characteristics and Risk Factors for Severe Japanese Spotted Fever: A Retrospective Multicenter Study in the Nagasaki Prefecture, Western Japan","volume":"78","author":"K Matsui","year":"2025","journal-title":"Jpn J Infect Dis"},{"issue":"9","key":"pntd.0014377.ref005","doi-asserted-by":"crossref","first-page":"1633","DOI":"10.3201\/eid2409.171436","article-title":"Distinguishing Japanese Spotted Fever and Scrub Typhus, Central Japan, 2004-2015","volume":"24","author":"E Sando","year":"2018","journal-title":"Emerg Infect Dis"},{"issue":"3","key":"pntd.0014377.ref006","doi-asserted-by":"crossref","first-page":"451","DOI":"10.4269\/ajtmh.14-0191","article-title":"Rickettsial infections in Southeast Asia: implications for local populace and febrile returned travelers","volume":"91","author":"AK Aung","year":"2014","journal-title":"Am J Trop Med Hyg"},{"key":"pntd.0014377.ref007","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1186\/1471-2334-10-108","article-title":"Clinical and laboratory findings associated with severe scrub typhus","volume":"10","author":"D-M Kim","year":"2010","journal-title":"BMC Infect Dis"},{"key":"pntd.0014377.ref008","unstructured":"Japan Institute for Health Security, Japan. Severe fever with thrombocytopenia syndrome (SFTS) in Japan, as of June 2019. 2019. Available from: https:\/\/id-info.jihs.go.jp\/niid\/en\/iasr\/9021-473te.html"},{"key":"pntd.0014377.ref009","doi-asserted-by":"crossref","DOI":"10.3949\/ccjm.84.s2.04","article-title":"Chi-square and Fisher\u2019s exact tests (From the \u201cBiostatistics and Epidemiology Lecture Series, Part 1\u201d)","volume":"84","author":"A Nowacki","year":"2017","journal-title":"Cleve Clin J Med"},{"issue":"4","key":"pntd.0014377.ref010","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1046\/j.1440-1754.2003.00141.x","article-title":"8: Non-parametric methods for continuous or ordered data","volume":"39","author":"JB Carlin","year":"2003","journal-title":"J Paediatr Child Health"},{"issue":"10","key":"pntd.0014377.ref011","doi-asserted-by":"crossref","first-page":"1099","DOI":"10.1111\/j.1553-2712.2011.01185.x","article-title":"Logistic regression: a brief primer","volume":"18","author":"JC Stoltzfus","year":"2011","journal-title":"Acad Emerg Med"},{"issue":"5","key":"pntd.0014377.ref012","doi-asserted-by":"crossref","DOI":"10.1093\/ofid\/ofae215","article-title":"Masqueraders Around Disaster: Clinical Features of Scrub Typhus in Fukushima, Japan","volume":"11","author":"M Narita","year":"2024","journal-title":"Open Forum Infect Dis"},{"issue":"5","key":"pntd.0014377.ref013","doi-asserted-by":"crossref","first-page":"1021","DOI":"10.4269\/ajtmh.16-0186","article-title":"Comparison of Preferred Bite Sites Between Mites and Ticks on Humans in Korea","volume":"95","author":"M-S Jang","year":"2016","journal-title":"Am J Trop Med Hyg"},{"issue":"4","key":"pntd.0014377.ref014","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1093\/qjmed\/hcaa331","article-title":"Japanese spotted fever and rickettsial pneumonia","volume":"114","author":"H Matsuura","year":"2021","journal-title":"QJM"},{"issue":"1","key":"pntd.0014377.ref015","doi-asserted-by":"crossref","DOI":"10.1002\/rcr2.70089","article-title":"Interstitial pneumonia due to Japanese spotted fever","volume":"13","author":"K Arai","year":"2025","journal-title":"Respirol Case Rep"},{"issue":"1","key":"pntd.0014377.ref016","doi-asserted-by":"crossref","first-page":"161","DOI":"10.1148\/rg.271065074","article-title":"Scrub typhus: clinical, pathologic, and imaging findings","volume":"27","author":"YJ Jeong","year":"2007","journal-title":"Radiographics"}],"updated-by":[{"DOI":"10.1371\/journal.pntd.0014377","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T00:00:00Z","timestamp":1779408000000}}],"container-title":["PLOS Neglected Tropical Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0014377","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,22]],"date-time":"2026-05-22T17:50:21Z","timestamp":1779472221000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0014377"}},"subtitle":[],"editor":[{"given":"Atsushi","family":"Togawa","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2026,5,20]]},"references-count":16,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2026,5,20]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pntd.0014377","relation":{},"ISSN":["1935-2735"],"issn-type":[{"value":"1935-2735","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,20]]}}}