Molecular Epidemiology of Ciprofloxacin-Resistant Escherichia coli Isolated from Community-Acquired Urinary Tract Infections in Korea

Background@#Escherichia coli is the predominant causative pathogen for community-acquired urinary tract infections (UTIs), and the increase in fluoroquinolone-resistant E. coli is of great concern in Korea. The objectives of this study were to investigate the genotypic characteristics and molecular epidemiology of ciprofloxacin-resistant (CIP-R) E. coli isolated from community-acquired UTIs in Korea. @*Materials and Methods@#E. coli samples isolated from the blood or urine were collected from patients with community-acquired acute pyelonephritis aged 15 years and more who were admitted to 12 Korean hospitals from 1st April 2010 to 29th February 2012. Phylogenetic typing, multilocus sequence typing, and molecular characterization of β-lactamase and plasmidmediated quinolone resistance determinants were performed for CIP-R E. coli isolates. @*Results@#A total of 569 E. coli isolates were collected, and 122 (21.4%) isolates were CIP-R isolates. The most prevalent sequence type (ST) was ST131 (28.7%, 35/122), followed by ST393 (14.7%, 18/122), ST1193 (13.1%, 16/122), ST38 (9.0%, 11/122), and ST405 (8.2%, 10/122). The antimicrobial resistance rates of ST131 to cefepime (22.9%, 8/35), ST38 to gentamicin (100%, 11/11), and ST405 to cefotaxime (66.7%, 6/9) were significantly higher than the resistance rates of all other STs combined. Notably, 40% (4/10) of ST405 clones produced extendedspectrum β-lactamases and were co-resistant to trimethoprim/sulfamethoxazole. aac(6′)-1b-cr (20%, 7/35) and CTX-M-14 (40%, 4/10) were more frequently observed in ST131 and ST405 compared with other clones, respectively. @*Conclusions@#Among the CIP-R uropathogenic E. coli isolates in this study, ST131, ST38, and ST405 were specifically associated with antimicrobial resistance.

The clinical and economic burden of community-onset complicated skin and skin structure infections in Korea

Background/Aims@#To investigate epidemiologic characteristics, clinical and economic burdens, and factors associated with mortality in complicated skin and skin structure infection (cSSSI) patients in Korea. @*Methods@#A retrospective, observational, nationwide study was conducted between April to July 2012 at 14 tertiary-hospitals in Korea. Eligible patients were hospitalized adults with community acquired cSSSI, who underwent surgical intervention and completed treatment between November 2009 and October 2011. Data on demography, clinical characteristics, outcomes and medical resource utilization were collected through medical record review. Direct medical costs were calculated by multiplying quantities of resources utilized by each unit price in Korea. @*Results@#Of 473 patients enrolled, 449 patients (except 24 patients with no record on surgical intervention) were eligible for analysis. Microbiological testing was performed on 66.1% of patients and 8.2% had multiple pathogens. Among culture confirmed pathogens (n = 297 patients, 340 episodes), 76.2% were gram-positive (Staphylococcus aureus; 41.2%) and 23.8% were gram-negative. The median duration of hospital stay was 16 days. Among treated patients, 3.3% experienced recurrence and 4.2% died in-hospital. The mean direct medical costs amounted to $4,195/ person, with the greatest expenses for hospitalization and antibiotics. The in-hospital mortality and total medical costs were higher in combined antibiotics therapy than monotherapy (p < 0.05). Charlson’s comorbidity index ≥ 3, standardized early warning scoring ≥ 4, sub-fascia infections and combined initial therapy, were all found to be associated with higher mortality. @*Conclusions@#Korean patients with community-onset cSSSI suffer from considerable clinical and economic burden. Efforts should be made to reduce this burden through appropriate initial treatment.

Antibiotic Treatment of Vertebral Osteomyelitis caused by Methicillin-Susceptible Staphylococcus aureus: A Focus on the Use of Oral β-lactams

BACKGROUND@#Vertebral osteomyelitis (VO) is a rare but serious condition, and a potentially significant cause of morbidity. Methicillin-susceptible Staphylococcus aureus (MSSA) is the most common microorganism in native VO. Long-term administration of parenteral and oral antibiotics with good bioavailability and bone penetration is required for therapy. Use of oral β-lactams against staphylococcal bone and joint infections in adults is not generally recommended, but some experts recommend oral switching with β-lactams. This study aimed to describe the current status of antibiotic therapy and treatment outcomes of oral switching with β-lactams in patients with MSSA VO, and to assess risk factors for treatment failure.@*MATERIALS AND METHODS@#This retrospective study included adult patients with MSSA VO treated at nine university hospitals in Korea between 2005 and 2014. Treatment failure was defined as infection-related death, microbiological relapse, neurologic deficits, or unplanned surgical procedures. Clinical characteristics and antibiotic therapy in the treatment success and treatment failure groups were compared. Risk factors for treatment failure were identified using the Cox proportional hazards model.@*RESULTS@#A total of 100 patients with MSSA VO were included. All patients were treated, initially or during antibiotic therapy, with one or more parenteral antibiotics. Sixty-nine patients received one or more oral antibiotics. Antibiotic regimens were diverse and durations of parenteral and oral therapy differed, depending on the patient and the hospital. Forty-two patients were treated with parenteral and/or oral β-lactams for a total duration of more than 2 weeks. Compared with patients receiving parenteral β-lactams only, no significant difference in success rates was observed in patients who received oral β-lactams for a relatively long period. Sixteen patients had treatment failure. Old age (adjusted hazard ratio [HR] 5.600, 95% confidence interval [CI] 1.402 – 22.372, P = 0.015) and failure to improve C-reactive protein levels at follow-up (adjusted HR 3.388, 95% CI 1.168 – 9.829, P = 0.025) were independent risk factors for treatment failure.@*CONCLUSION@#In the study hospitals, diverse combinations of antibiotics and differing durations of parenteral and oral therapy were used. Based on the findings of this study, we think that switching to oral β-lactams may be safe in certain adult patients with MSSA VO. Since limited data are available on the efficacy of oral antibiotics for treatment of staphylococcal VO in adults, further evaluation of the role of oral switch therapy with β-lactams is needed.

Preliminary Report of Seroprevalence of Anti-Measles Immunoglobulin G among Healthcare Workers of 6 Teaching Hospitals of Daegu, Korea in 2019

The measles outbreak in Daegu of January 2019 made 6 teaching hospitals' organization test the measles immunity of their healthcare workers (HCWs). We found that 6,935 (75.9%) of 9,132 HCWs tested seropositive for anti-measles immunoglobulin G (IgG), and seropositivity rate was very different between 6 hospitals (range, 59.9–93.1%). The seroprevelence was lowest in the age of twenties, but the rate was different between 6 hospitals (range 47.0–85.5%). Therefore, to prevent measles from spreading to HCWs, each hospital should make their own data periodically about anti-measles IgG seropositivity of their HCWs.

Comparison of Escherichia coli and Klebsiella pneumoniae Acute Pyelonephritis in Korean Patients

BACKGROUND@#Escherichia coli and Klebsiella pneumoniae are two of the most common causes of urinary tract infection. The purpose of this study was to compare clinical characteristics and antimicrobial susceptibility of acute pyelonephritis (APN) between E. coli and K. pneumoniae.@*MATERIALS AND METHODS@#We retrospectively reviewed medical records of patients with APN due to E. coli and K. pneumoniae between February 2014 and October 2017.@*RESULTS@#A total 329 patients were enrolled; 258 cases of E. coli and 71 cases of K. pneumoniae. Among them, 219 cases were categorized into community-onset APN; 194 cases of E. coli and 25 cases of K. pneumoniae, and 110 patients were categorized into healthcare-associated APN; 64 cases of E. coli and 46 cases of K. pneumoniae. Catheter-associated APN was more frequently observed in K. pneumoniae in both community-onset and healthcare-associated APN. Neurogenic bladder, obstructive uropathy, urinary tract stone, bacteremia, and severe APN were more related to E. coli in healthcare-associated APN. In multivariate analysis, urinary catheter was more associated with K. pneumoniae (odds ratio [OR] 9.643, 95% confidence intervals [CI] 4.919-18.904, P = 0.001) and neurogenic bladder was more associated with E. coli (OR 3.765, 95% CI 1.112-12.772, P = 0.033). Extended-spectrum β-lactamase (ESBL) production was observed in 29.0% of E. coli in community-onset APN. Among ESBL, antimicrobial susceptibility of piperacillin/tazobactam was significantly higher in E. coli and ciprofloxacin was significantly higher in K. pneumoniae.@*CONCLUSION@#K. pneumoniae were more associated with urinary catheter while E. coli tended to be more associated with urogenital problems. ESBL positivity showed no significance in healthcare-associated APN. In community-onset APN, ESBL producing E. coli was more observed than K. pneumoniae.

Unusual Presentation of Subcutaneous Phaeohyphomycosis by Alternaria alternate

The Alternaria species are dematiaceous fungi. Human infection due to dematiaceous fungi is uncommon. Most reported cases of alternariosis have occurred in patients with immunodeficiency. The majority of cases were solid-organ transplantation recipients. Cutaneous alternariosis lesions are usually asymptomatic solitary nodules, plaques of ulcers or subcutaneous cysts. Here we report a case of a 77-year-old female who presented with hemorrhagic skin necrosis in right arm that had developed from hemorrhagic bullae. Her prior medical history included iatrogenic Cushing's syndrome, hypertension, interstitial lung disease and congestive heart failure. Following administration of itraconazole, her lesions improved.

Safety and Effectiveness of Peramivir in Korean Adult Influenza Patients: Prospective Observational Study Based on Post-Marketing Surveillance Data

BACKGROUND: The safety and clinical effectiveness data of peramivir in the real clinical field are limited. A prospective observational study was conducted based on the post-marketing surveillance data to evaluate the post-marketing safety and effectiveness of peramivir in Korean adults with seasonal influenza. METHODS: Among adults aged 20 years or older who were diagnosed with influenza A or B, patients who started peramivir within 48 hours from the initial symptoms of influenza were enrolled. All adverse events (AEs) that occurred within 7 days after administration of peramivir were checked. For the evaluation of effectiveness, changes in the severity of influenza symptoms and daily living performance were examined before and 7 days after the administration of peramivir. The date on which influenza related symptoms disappeared was checked. RESULTS: A total of 3,024 patients were enrolled for safety evaluation and 2,939 patients were for effectiveness evaluation. In the safety evaluation, 42 AEs were observed in 35 (1.16%) patients. The most common AE was fever. AEs were mostly rated as mild in severity. Serious AEs were observed in 10 patients and two of them died. However, both deaths were considered to be less relevant to peramivir. In the effectiveness evaluation, the severity of influenza symptoms decreased by 10.68 ± 4.01 points and daily living performance was improved 5.59 ± 2.16 points. Influenza related symptoms disappeared on average 3.02 ± 2.39 days after peramivir administration. CONCLUSION: Peramivir showed a tolerable safety profile and acceptable effectiveness in Korean adult patients with seasonal influenza.

Incidence and Associated Factor of Adverse Events of Tigecycline Therapy in Korean Patients / 계명의대학술지

Tigecycline is a broad spectrum antibiotic which has been used for complicated intra-abdominal infection and complicated skin and soft tissue infection by multi-drug resistant bacteria. However recent meta-analysis studies have raised a concern for adverse events of tigecycline. We analyzed retrospectively adverse events, associated factors of adverse events in multi-drug resistant bacteria caused infections treated with tigecycline in Korean patients. One hundred-sixty patients treated with tigecycline from July 2009 to September 2013 were enrolled in this study. Their clinical and microbiologic data were reviewed. History of invasive procedure within 7 days and recent operation within 3 months were associated with adverse events. The most common adverse events were nausea and vomiting. Associated factors of nausea were soft tissue injury and recent operation within 3 months. In this study, nausea was the most common adverse event in patients who received tigecycline. Although it is not serious complication, monitoring of adverse events is required to increase compliance.

Changing trends in clinical characteristics and antibiotic susceptibility of Klebsiella pneumoniae bacteremia

BACKGROUND/AIMS: Klebsiella pneumoniae is second most common organism of gram-negative bacteremia in Korea and one of the most common cause of urinary tract infection, and intra-abdominal infection. METHODS: We compared clinical and microbiological characteristics about K. pneumoniae bacteremia in a tertiary hospital between 10 years. Group A is who had K. pneumoniae bacteremia at least one time from January 2004 to December 2005. Group B is from January 2012 to December 2013. We also analyzed antibiotic resistance, clinical manifestation of the K. pneumoniae bacteremia divided into community-acquired infections, healthcare associated infections, and nosocomial infections. RESULTS: The resistance for ampicillin, aztreonam, cefazolin, and cefotaxime significantly increased compared to 10 years ago. Extended spectrum β-lactamase positivity surged from 4.3% to 19.6%. Ten years ago, 1st, 2nd cephalosporin, and aminoglycoside were used more as empirical antibiotics. But these days, empirical antibiotics were broad spectrum such as 3rd and 4th cephalosporin. In treatment outcome, acute kidney injury decreased from 47.5% to 28.7%, and mortality decreased from 48.9% to 33.2%. In community-acquired infections, there was similar in antimicrobial resistance and mortality. In healthcare-associated and nosocomial infections, there was significantly increasing in antibiotic resistance, decreasing in mortality, and acute kidney injury. CONCLUSIONS: In community-acquired infections, broader antibiotics were more used than 10 years ago despite of similar antimicrobial resistance. When K. pneumoniae bacteremia is suspected, we recommend to use the narrow spectrum antibiotics as initial therapy if there are no healthcare-associated risk factors, because the antibiotic resistance is similar to 10 years ago in community-acquired infections.

Eight Cases of Dengue Fever in a Volunteer Group from Sri Lanka and Its Ocular Involvement / 대한내과학회지

Dengue fever is an acute febrile disease that is caused by a mosquito-borne flavivirus. It has become a major infectious disease threat in tropical and subtropical areas. In Korea, travel-associated dengue fever is increasing. Thirty-five Koreans went to Sri Lanka to do volunteer activities. Eight of the volunteers developed fever, myalgia, and rash; they were diagnosed with dengue fever. Two patients had macular hemorrhages and edema with no ophthalmic symptoms. The maculopathy caused by the dengue fever improved without specific treatment.

Association of biofilm production with colonization among clinical isolates of Acinetobacter baumannii

BACKGROUND/AIMS: The pathogen Acinetobacter baumannii is increasingly causing healthcare-associated infections worldwide, particularly in intensive care units. Biofilm formation, a factor contributing to the virulence of A. baumannii, is associated with long-term persistence in hospital environments. The present study investigates the clinical impact of biofilm production on colonization and acquisition after patient admission. METHODS: Forty-nine A. baumannii isolates were obtained between August and November 2013 from Keimyung University Dongsan Medical Center, Daegu, Korea. All isolates were obtained from sputum samples of new patients infected or colonized by A. baumannii. The microtiter plate assay was used to determine biofilm formation. RESULTS: Twenty-four A. baumannii isolates (48%) demonstrated enhanced biofilm formation capacity than that of the standard A. baumannii strain (ATCC 19606). All isolates were resistant to carbapenem, 38 isolates (77%) were collected from patients in an intensive care unit, and 47 isolates (95%) were from patients who had been exposed to antibiotics in the previous month. The median duration of colonization was longer for biofilm-producing isolates than that of the biofilm non-biofilm producing isolates (18 days vs. 12 days, p < 0.05). Simultaneous colonization with other bacteria was more common for biofilm-producing isolates than that for the non-biofilm producing isolates. The most prevalent co-colonizing bacteria was Staphylococcus aureus. CONCLUSIONS: Biofilm-producing isolates seem to colonize the respiratory tract for longer durations than the non-biofilm producing isolates. During colonization, biofilm producers promote co-colonization by other bacteria, particularly S. aureus. Additional research is required to determine possible links between biofilm formation and nosocomial infection.

Effect of Early Plasma Exchange on Survival in Patients with Severe Fever with Thrombocytopenia Syndrome: A Multicenter Study

Despite a high mortality rate, no specific treatment for severe fever with thrombocytopenia syndrome (SFTS) has been established. This study compared the clinical outcomes of SFTS patients treated with plasma exchange (PE group) with those who were not treated (non-PE group) at nine Korean hospitals between May 2013 and August 2015. A total of 53 SFTS patients were included: 24 (45.3%) PE cases and 29 (54.7%) non-PE cases. The overall in-hospital mortality rate was 32.1% (17/53). The in-hospital mortality rate of the PE group did not differ from that of the non-PE group (29.3% vs. 34.5%, p=0.680). Of the 24 PE cases, 16 (66.7%) were treated with PE within 7 days of symptom onset (early PE group). The early PE group survived longer than the non-PE group (mean 28.4 days vs. 22.6 days, p=0.044). Multivariate analysis showed an inverse association between early PE implementation and 30-day mortality (adjusted hazard ratio 0.052, 95% confidence interval 0.004–0.678, p=0.024). The results of this study suggest that early PE implementation may have a beneficial effect on the clinical outcome of SFTS patients.

Usefulness of Blood Cultures and Radiologic Imaging Studies in the Management of Patients with Community-Acquired Acute Pyelonephritis

BACKGROUND: The objective of this study was to examine the usefulness of blood cultures and radiologic imaging studies for developing therapeutic strategies in community-acquired acute pyelonephritis (CA-APN) patients. MATERIALS AND METHODS: We prospectively collected the clinical data of CA-APN patients who visited 11 hospitals from March 2010 to February 2011. RESULTS: Positive urine and blood cultures were obtained in 69.3% (568/820) and 42.7% (277/648), respectively, of a total of 827 CA-APN patients. Blood culture identified the urinary pathogen in 60 of 645 (9.3%) patients for whom both urine and blood cultures were performed; the organisms isolated from urine were inconsistent with those from blood in 11 and only blood cultures were positive in 49 patients. Final clinical failure was more common in the bacteremic patients than the non-bacteremic ones (8.0% vs. 2.7%, P = 0.003), as was hospital mortality (3.6% vs. 0.3%, P = 0.003). Likewise, durations of hospitalization and fever were significantly longer. Bacteremia was independent risk factor for mortality (OR 9.290, 1.145-75.392, P = 0.037). With regard to radiologic studies, the detection rate of APN was 84.4% (445/527) by abdominal computed tomography and 40% (72/180) by abdominal ultrasonography. Eighty-one of 683 patients (11.9%) were found to have renal abscess, perinephric abscess, urolithiasis, hydronephorosis/hydroureter or emphysematous cystitis, which could potentially impact on clinical management. Patients with Pitt score ≥ 1, flank pain or azotemia were significantly more likely to have such structural abnormalities. CONCLUSION: Blood cultures are clinically useful for diagnosis of CA-APN, and bacteremia is predictive factor for hospital mortality. Early radiologic imaging studies should be considered for CA-APN patients with Pitt scores ≥1, flank pain or azotemia.

Simultaneous Diagnosis of Pneumococcal Sepsis and Disseminated Mycobacterium avium Complex Infection in a Patient with Acquired Immunodeficiency Syndrome / 대한내과학회지

The incidence of bacteremia in human immunodeficiency virus (HIV)-infected patients is significantly decreased by highly active antiretroviral therapy (HAART). However, bacteremia remains a major cause of morbidity and mortality in HIV-infected patients. A 43-year-old male who had fever and cough for 1 week presented to the emergency room. He was diagnosed with acquired immunodeficiency syndrome combined with atypical pneumonia and started on antibiotics plus HAART. After 3 days, Streptococcus pneumoniae was grown in blood cultures. Three weeks later, acid-fast bacilli cultures of blood and bronchoalveolar lavage fluid grew Mycobacterium avium complex (MAC); hence, the patient was treated with antimycobacterial drugs. HIV-infected patients with persistent fever despite administration of appropriate antibiotics should be examined for simultaneous infection by other organisms, such as nontuberculous mycobacteria. We report a case of simultaneous detection of MAC and S. pneumoniae in the blood of a treatment-naïve HIV-infected patient.

Influenza / 대한내과학회지

Influenza causes variable epidemics annually and imposes public health problems and socioeconomic burden. They cause epidemic acute respiratory disease, characterized by fever, cough and systemic symptoms. The annual epidemics of seasonal influenza can affect any age group and result in serious illness or death, particularly in high risk populations such as adults > 65 years old, children < 2 years old and those with chronic medical condition at any age. Three types (A, B, and C) are recognized as well as many subtypes within the type A. New influenza A virus subtypes sporadically emerge in humans to cause widespread disease or pandemics. Antiviral therapy with oseltamivir or zanamivir is available and shorten the duration of illness and reduce the rate of complications. Influenza vaccines are effective in the prevention of influenza illness, although improved vaccines are needed.

Recurrent Kikuchi's Disease Treated by Hydroxychloroquine

Kikuchi-Fujimoto disease (KFD) is a benign, self-limiting disease, with a specific histopathology. It can be diagnosed clinically, and specific symptoms include fever and cervical lymphadenopathy. The histological finding of KFD in cervical lymph nodes includes necrotizing lymphadenitis. KFD needs conservative treatments. If KFD persists for a long period, steroids or nonsteroidal antiinflammatory drugs can be used to control symptoms. Previous studies have reported the treatment of KFD with hydroxychloroquine (HC) in patients unresponsive to steroids. Herein, we report a case of a 25-year-old female patient diagnosed with KFD unresponsive to steroids, and was successfully treated with HC.

Lymphangioma involving whole mesentery confirmed by core needle biopsy / 영남의대학술지

Lymphangiomas are malformations of the lymphatic system accounting for approximately 5% of all benign tumors in infants and children. Abdominal lymphangiomas are rare, and can arise from either the retroperitoneum, gastrointestinal tract, or the mesentery of the abdominal viscera. Lymphangioma involving the whole mesentery is particularly rare. Most lymphangiomas are detected during infancy or childhood, but intraabdominal lymphangiomas such as mesentery are not found until adulthood. We report here on a patient with uncommon lymphangioma involving the whole mesentery who presented with fever and abdominal pain. This patient is unusual because he was confirmed through core needle biopsy which showed variable sized lymphatic spaces representing a immunoreactive for D2-40 antibody with involvement of the whole mesentery. No cases of mesenteric lymphangioma confirmed preoperatively have been previously reported in Korea.

Effects of Candidemia Surveillance to Earlier Use of Antifungal Agents and Ophthalmologic Examinations / 계명의대학술지

Candidemia is increasing cause of mortality, especially in intensive care unit patients. And Candida endophthalmitis, developed with or without symptoms, has poor outcome. Prompt use of antifungal agents and early diagnosis of Candida endophthalmitis are clinically important to treat candidemia. In this study, we compared clinical, microbiological, ophthalmological characteristics and treatment outcomes whether infectious disease (ID) specialists mediate candidemia or not in a tertiary hospital by retrospective chart review. Group A includes patients who had candidemia at least one time from January 2012 to July 2013, without ID specialists mediation. Group B includes patients who had candidemia at least one time from August 2013 to December 2014, with ID specialists surveillances and mediations. We compared clinical manifestations of candidemia, uses of antifungal agent, ophthalmologic evaluations and treatment outcomes between two groups. In group A, rate of ophthalmologic evaluations was 4.4% and mean duration was 64.60 hours from blood culture to use of antifungal agents. In group B, the rate of ophthalmologic evaluations was 43.2% and mean duration was 50.15 hours. There was no statistically significant difference in clinical characteristics and 30-day mortality between two groups. Increasing rate of ophthalmologic evaluations and decreasing mean duration from blood culture to use of antifungal agents was shown in surveillance and mediation group.

Primary Bacteremia in Diabetes Patient Caused by Non-O1/non-O139 Vibrio cholerae / 계명의대학술지

Vibrio cholerae (V. cholerae) serotype O1 or O139 is the etiological agents of cholera. These bacteria are responsible for gastrointestinal infections or more rarely bacteremia in patients with an underlying disease, leading to life-threatening complications. A 73-year-old man presented to the hospital with fever and vomiting. Blood cultures grew non-O1/non-O139 V. cholerae. In this case, clinical improvement and microbiological eradication were achieved due to early appropriate antibiotic therapy. These results suggest that early antibiotic therapy allowed a good outcome in diabetic patient infected with V. cholerae . To our knowledge, this is the first case of primary bacteremia caused by non-O1/non-O139 Vibrio cholera in Korea.

Pulmonary Embolism Associated with Scrub Typhus / 대한내과학회지

Acute pulmonary embolism is a cardiovascular emergency and is a major cause of morbidity and mortality. Endothelial damage secondary to invasion by Orientia tsutsugamushi can lead to focal occlusive endangiitis, causing microinfarcts in various tissues. This localized process can also cause venous thrombosis and peripheral gangrene. However, pulmonary embolism associated with scrub typhus has not been reported in Korea. Here, we report a patient diagnosed with pulmonary embolism associated with scrub typhus, the first report of its kind. The patient had an eschar with detection of anti-tsutsugamushi antibody, fever, dyspnea, and a maculopapular rash over the entire body. He was treated with doxycycline and anticoagulation therapy.