Facial Rash Research Articles

Milian’s ear sign of erysipelas

A 65-year-old woman presented with 2 days of acute onset fever, with left pinna pain, swelling and erythema (figures 1 and 2). She had no significant medical history. Physical examination...

Rare occurrence of central diabetes insipidus with dermatomyositis in a young male.

SummaryCentral diabetes insipidus (CDI) and several endocrine disorders previously classified as idiopathic are now considered to be of an autoimmune etiology. Dermatomyositis (DM), a rare autoimmune condition characterized by inflammatory myopathy and skin rashes, is also known to affect the gastrointestinal, pulmonary, and rarely the cardiac systems and the joints. The association of CDI and DM is extremely rare. After an extensive literature search and to the best of our knowledge this is the first reported case in literature, we report the case of a 36-year-old male with a history of CDI, who presented to the hospital’s endocrine outpatient clinic for evaluation of a 3-week history of progressive facial rash accompanied by weakness and aching of the muscles.Learning points:Accurate biochemical diagnosis should always be followed by etiological investigation.This clinical entity usually constitutes a therapeutic challenge, often requiring a multidisciplinary approach for optimal outcome.Dermatomyositis is an important differential diagnosis in patients presenting with proximal muscle weakness.Associated autoimmune conditions should be considered while evaluating patients with dermatomyositis.Dermatomyositis can relapse at any stage, even following a very long period of remission.Maintenance immunosuppressive therapy should be carefully considered in these patients.

Demodex Folliculorum Infestation Mimicking Acute Cutaneous GVHD

<h3>Introduction</h3> Demodex folliculorum (DF) mites are inhabitants of the human pilosebaceous unit and are part of normal skin flora. They have a predilection for the face due to high sebum concentration in this area. While rarely symptomatic in the immunocompetent, (DF) mites are found in greater density and are more pathogenic in the immunocompromised. Symptomatic DF infestations in the immunocompromised have been described in the past; however, there is scarce literature regarding this condition in hematopoietic stem cell transplant (tx) recipients, where its clinical presentation is like acute graft versus host disease (aGvHD) of the skin. <b>Case:</b> A 73-year-old male diagnosed with AML underwent reduced-intensity peripheral blood matched unrelated donor tx. GvHD prophylaxis was with post-tx cyclophosphamide and cyclosporine. Post-tx day 32, he presented with sudden onset facial puffiness, redness and bilateral periorbital edema (figure 1). On physical exam, he had bilateral periorbital edema with thickened red skin over the forehead, cheeks, mandible, and submandibular areas. He had a skin biopsy and due to concerns of aGVHD, he was treated with topical hydrocortisone, oral antihistamines, and systemic corticosteroids. While his symptoms improved, the rash did not resolve. Biopsy showed mixed perifollicular inflammation with DF mites (figure 2). Based on these findings he was treated with 2 doses of Ivermectin 200 mcg/kg and the rash completely resolved. <h3>Discussion</h3> There have been a few reports of DF infestation in tx patients, most presented within 100 days of tx mimicking aGvHD. However, a few have, reported onset of rash after the withdrawal of immunosuppression, presenting like cutaneous late aGvHD. In all these cases, the patient presented with a characteristic facial rash with a sharp demarcation between the scalp and forehead known as the "cut off" sign. The tendency to spare the scalp may be due to the differences in the pilosebaceous units of the scalp compared with those on the face, this may help distinguish it from cutaneous aGvHD. Treatment with mite directed therapy can rapidly treat this condition.

Facial and oropharyngeal angioedema after tenecteplase treatment of acute myocardial infarction

Angioedema and type I allergic reactions are rare but recognized side effects of thrombolytic drugs. They are more commonly reported during or after the treatment of acute ischemic stroke with alteplase compared to myocardial infarction (MI). Herein, we present a 68-year-old male patient who developed oropharyngeal and facial angioedema and urticarial skin rash on the upper limbs after treatment of acute MI with tenecteplase.

LBA90 - Primary analysis results of randomized controlled trial evaluating reactive topical corticosteroid strategies for the facial acneiform rash by EGFR inhibitors (EGFRIs) in patients (pts) with RAS wild-type (wt) metastatic colorectal cancer (mCRC): FAEISS study

BackgroundThe management strategies regarding the strength of reactive topical corticosteroids have not been well evaluated in clinical trials. This FAEISS study is designed to confirm the superior efficacy of reactive topical corticosteroid strategies with serially ranking-DOWN from very strong levels compared with those with serially ranking-UP from weak levels for facial acneiform rash induced by EGFRI. MethodsPts with RAS wt mCRC were enrolled in the first registration. All pts received pre-emptive therapy with oral minocycline 100 or 200mg/day and heparinoid moisturizer from the initiation of EGFRIs. Enrolled pts who developed facial acneiform rash within 8 weeks were randomized either to ranking-UP group (UP group) or ranking-DOWN group (DOWN group) (second registration) using minimization method for balancing institution, type of EGFRIs, and sex. Primary endpoint was incidence of Grade2 (moderate) or higher facial acneiform rash during 8 weeks after randomization. Results172 RAS wt mCRC pts, of whom 22 pts and 84 pts received cetuximab and panitumumab, respectively, were enrolled and 106 pts were randomized. There was no significant difference in the incidence of Grade 2 ≧ facial acneiform rash between UP group (18 times) and DOWN group (20 times) (stratified Wilcoxon’s rank sum test, one-sided: p=0.86221). As for secondary end points, proportion of Grade3 or higher facial acneiform rash was 13.2% for UP group and 11.3% for DOWN group, showing no significant difference between the groups (Fisher’s exact test: p=1.0000). There was no problem of safety concern in both groups. ConclusionsTopical corticosteroids ranking UP from weak levels was confirmed to be standard therapy for the management of facial acneiform rash in pts with RAS wt mCRC. It would follow that minocycline and heparinoid moisturizer have a prophylactic efficacy while topical corticosteroids have a therapeutic efficacy for facial acneiform rash. Clinical trial identificationUMIN000024113. Legal entity responsible for the studyFAEISS Study Group. FundingAMED. DisclosureN. Yamazaki: Honoraria (self), Research grant / Funding (institution): Takarabio; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Ono; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Bristol-Myers Squibb; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): MSD; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Novartis. K. Kikuchi: Research grant / Funding (institution): POLA; Research grant / Funding (institution): Maruho. H. Fukuda: Honoraria (self): Taiho/chugai; Research grant / Funding (self): National Cancer Center. T. Hamaguchi: Honoraria (self), Research grant / Funding (institution): Ono; Honoraria (self): Takeda; Honoraria (self): Bayer. N. Boku: Honoraria (self), Research grant / Funding (institution): Taiho; Honoraria (self), Research grant / Funding (institution): Ono; Honoraria (self), Research grant / Funding (institution): Bristol-Myers Squibb. T. Takenouchi: Speaker Bureau / Expert testimony: Ono; Speaker Bureau / Expert testimony: MSD; Speaker Bureau / Expert testimony: Novartis . T. Nishina: Honoraria (self), Research grant / Funding (institution): Taiho; Honoraria (self), Research grant / Funding (institution): Chugai; Honoraria (self), Research grant / Funding (institution): Merck Serono. S. Yoshikawa: Honoraria (self): Ono; Honoraria (self): Novertis; Honoraria (self): Bristol-Myers Squibb. K. Yamazaki: Honoraria (self): Chugai; Honoraria (self): Daiichi Sankyo. M. Takahashi: Speaker Bureau / Expert testimony, Research grant / Funding (institution): Ono; Speaker Bureau / Expert testimony: Daiichi Sankyo. T. Masuishi: Honoraria (self): Taiho; Honoraria (self): Merck Serono; Honoraria (self): Yakult Honsha. Y. Kiyohara: Honoraria (self), Research grant / Funding (institution): MSD; Honoraria (self), Research grant / Funding (institution), Travel / Accommodation / Expenses: Ono; Honoraria (self), Research grant / Funding (institution): BMS. All other authors have declared no conflicts of interest.

The Effectiveness of Hemodialysis in case of Intoxication with Pregabalin

Although it was originally developed for the treatment of epilepsy, pregabalin has also been used frequently in the management of neuropathic pain and anxiety disorders recently. Owing to its widespread use in this regard, number of the cases reported with regard to both its side-effects and overdose has been escalating dramatically. More specifically, facial rash, dizziness, drowsiness, peripheral edema and weigh gain, hyponatremia and increase in systolic dysfunction especially in the elderly, hepatotoxicity and transient encephalopathy were reported with increasing incidence in the literature. We hereby reported a case of seizure and metabolic acidosis incited by pregabalin overdose, and our aim is to constitute an appeal for the fact that implementation of hemodialysis is a rapid and effective method in the treatment of seizure and metabolic acidosis in case of pregabalin intoxication.

P2.14-23 Initial Analysis in NSCLC Part of Randomized Trial Evaluating Topical Corticosteroid for the Facial Acneiform Rash by EGFR Inhibitors

P2.14-23 Initial Analysis in NSCLC Part of Randomized Trial Evaluating Topical Corticosteroid for the Facial Acneiform Rash by EGFR Inhibitors

2328 Ectopic Liver: A Silent Killer

INTRODUCTION: We present a rare case of Ectopic Liver (EL) tissue along the pancreatic tail, that developed into HCC. Based on our research, there are only 4 reported cases of primary HCC in EL tissue around the pancreas. Our case originates in the retroperitoneum near the pancreas. CASE DESCRIPTION/METHODS: 70 y.o Female with Tuberous Sclerosis was referred for an incidental finding of an abdominal mass. She was seen by her PCP for back pain and difficulty ambulating. Physical exam showed chronic facial rash. Abdominal exam was negative for a palpable mass, tenderness, guarding or rebound. Labs revealed normal LFTs and normocytic anemia. Viral hepatitis panel was negative. MRI abdomen showed a 6.8 × 7 cm mass in the LUQ with a central cystic cavity and a surrounding solid component.The mass abuted the pancreatic tail and loops of bowel and was of unclear origin. EUS showed a normal appearing pancreas. A hypoechoic mass with cystic and solid components was noted next to the pancreas. FNA was performed. Immunohistochemical staining was positive for Hepatocyte specific antigen (HSA), supporting hepatic origin and CK7 highlighting the presence of a bile ductules. This supported the diagnosis of hepatic tissue. Surgical resection was recommended. A 8 cm mass involving the splenic vein and pancreatic tail was noted and distal pancreatectomy and splenectomy was performed. Surgical pathology showed carcinoma with hepatic differentiation, most consistent with primary HCC, adherent to the pancreas, but not involving the pancreatic parenchyma. No benign liver tissue was identified. A diagnosis of HCC arising within and replacing a rest of ectopic liver was made. AFP post-op was normal. Post-op course was uneventful. DISCUSSION: EL is defined as liver tissue found outside and not in communication with the normal liver. It is susceptible to same diseases as normal liver and especially prone to malignancy, despite the lack of risk factors. Given the difference in arteriovenous and bile system, EL tissue may have longer exposure to carcinogens. MRI shows "post contrast peripheral solid enhancement" - suggestive of HCC with ectopic tissue enhancement in arterial phase, however is less highlighted compared to HCC in normal liver. AFP is &gt; 20ng/mL in 60% cases. Surgical resection is the primary treatment with no reported tumor recurrence. Our case highlights the importance that any EL is at high risk for HCC development, despite the lack of risk factors and negative FNA biopsies and surgical therapy needs to be offered.

Dermatomyositis Presented with Facial Rash in a 40 Years Old Lady in Bangladesh: A Case Report

Dermatomyositis is overly simplified as inflammatory myopathy with characteristic rashes. Understanding dermatomyositis is challenging because firstly presentation may be non-specific, vague and delayed. Secondly there is no specific diagnostic test or universally acceptable diagnostic criteria. Therefore, to missed or delayed diagnosis results in failure to treatment. A forty year old lady with facial rash and generalized weakness was diagnosed with dermatomyositis on the basis of generalized weakness, typical facial rash with very high CK and eletrophysiological study. Steroid treatment initially improved her symptoms.&#x0D; Journal of National Institute of Neurosciences Bangladesh, 2019;5(2): 191-193

Suspected inflammatory rheumatic diseases in patients presenting with skin rashes.

Skin lesions occur, often at very early stages, in many of the most frequent inflammatory rheumatic diseases such as in systemic lupus erythematosus (SLE), dermatomyositis (DM), systemic sclerosis (SSc), Sjögren's syndrome, rheumatoid arthritis (RA), and psoriatic arthritis. It is important to recognize the different specific cutaneous lesions in SLE (e.g., "butterfly" rash in acute, annular or psoriasiform photosensitive lesions in the subacute form, and discoid lesions in the chronic form) for an early diagnosis and to estimate the associated risks of internal disease, whereas nonspecific lesions (exanthema, vasculitis, and alopecia) can be part of SLE flares. Cutaneous lesions in DM (Gottron's papules and sign, heliotrope rash, dystrophic cuticles, and nailfold capillary abnormalities) may occur before any clinically evident muscular or systemic organ involvement and are of utmost importance for early diagnosis. The pattern of cutaneous lesions and associated autoantibodies also allow the distinction of different phenotypes, either more prone to life-threatening interstitial lung disease (MDA-5) or with higher risk for neoplasia (TIF1-γ). Many other skin lesions, although not specific, require further investigation to look for a possible underlying inflammatory rheumatic disease: non-pruritic urticarial lesions in anti-C1q-associated urticarial vasculitis, Still's disease or hereditary auto-inflammatory syndromes, transient macular purpura of vasculitis in Sjögren's syndrome, Behçet's disease, or RA, Raynaud's phenomenon in SSc and mixed connective tissue disease, erythema nodosum or other panniculitis in RA, Behçet's disease and SLE, pustular eruptions in Behçet's disease, psoriasis, and hereditary auto-inflammatory syndromes. After reviewing in detail the cutaneous manifestations of the most frequent inflammatory rheumatic diseases, we describe a topographic and morphological approach to skin rashes, calling attention to facial rashes, hand involvement, scalp, nail, or leg lesions or to some morphological aspects of skin lesions (annular, pustular, urticarial, or exanthematous) that may be the initial manifestations of inflammatory rheumatic diseases. The importance of skin lesions is confirmed by their presence as part of the classification criteria of many inflammatory rheumatic diseases. They also contribute to early diagnosis, to characterize disease phenotypes, to aid in effective patient management, and, ultimately, to impact on disease prognosis.

Janus kinase 1/2 inhibition for the treatment of autoinflammation associated with heterozygous TNFAIP3 mutation

Janus kinase 1/2 inhibition for the treatment of autoinflammation associated with heterozygous TNFAIP3 mutation

Nailfold capillary changes in adult new-onset dermatomyositis: a prospective cross-sectional study.

It is to prospectively analyze nailfold capillaroscopy (NC) findings in new-onset dermatomyositis (DM) and to correlate NC findings with serum angiogenic cytokines and DM clinical and laboratory features. Twenty-three patients with DM who experienced < 12months of symptoms were included in the study. To assess serum cytokine levels, 23 age-, sex-, and ethnicity-matched healthy volunteers were used. NC characteristics and DM activity parameters were analyzed. Significantly higher serum angiogenin (ANG) and vascular endothelial growth factor-1 (VEGF1) levels were observed in DM patients than in controls. Capillary density and avascular areas correlated positively and negatively, respectively, with serum levels of ANG. Moreover, the capillary density correlated inversely with the number of enlarged and giant capillaries and avascular areas. The number of enlarged capillaries correlated positively with patient and physician visual analogue scales (VAS), the presence of a facial rash, giant capillaries, and microhemorrhages. Giant capillaries had a positive correlation with physician and cutaneous VAS, enlarged capillaries, avascular areas, microhemorrhages and bushy capillaries, and a negative correlation with capillary density. Microhemorrhages correlated positively with the "V-neck" sign and physician VAS. VEGF1 showed no relationship with the NC parameters with DM-related clinical and laboratory features. Additionally, 15 out of 23 patients were assessed prospectively after 3.21years. All patients had a major clinical response with significant improvement in all NC parameters, except for enlarged and bushy capillaries. The NC may be a useful tool to assess disease activity in recent-onset DM, and it can also reinforce the role of ANG in the angiogenesis of this myopathy.

535 New regional dermatoses during dupilumab therapy for atopic dermatitis

Dupilumab is a monoclonal antibody targeting IL-4Ra used for treating atopic dermatitis (AD). A subset of AD patients develops new regional dermatoses (NRDs) on dupilumab therapy. Apart from limited case reports and series, little is known about these NRDs. We conducted a retrospective cohort study at a single academic site to describe the prevalence, clinical features, and management of NRDs among all adults treated with dupilumab for AD. NRDs were defined as eruptions that (1) occur in a new anatomic region, (2) be resistant to usual topicals used, (3) occur on uninterrupted dupilumab therapy, (4) occur following primary therapeutic response, and (5) not be explained by a different entity. Following institutional review board approval, a clinical data warehouse was queried for all adults receiving dupilumab for AD prior to November 1, 2018. 73 patients were included for analysis, of which 17 (23%) had NRDs. 14 had facial rash and 4 had a history of patch test-confirmed allergic contact dermatitis (ACD). The predominant morphologies were eczematous (12/17) and erythema (4/17). Most (11/17) were treated with topical corticosteroids. Four stopped dupilumab due to NRDs. Two NRDs were biopsied: one showed rosacea and the other showed resolving VZV. Two patients with NRDs had negative patch testing to at least 80 allergens within 2 years prior to starting dupilumab. New facial dermatitis while on treatment with dupilumab has been reported and suspected to represent unrecognized ACD. However, ACD likely does not explain all cases, as 2 patients with NRDs in this cohort had negative comprehensive patch testing. Unmasking of another primary dermatosis in an altered cutaneous immune milieu may explain the facial erythema seen in 4 subjects, one of whom had biopsy-proven rosacea. The retrospective study design and lack of diagnostic workup for most NRDs are weaknesses of this study. Larger studies involving biopsy and patch testing are needed to establish their etiology.

Comparative Efficacy and Safety of Low Dose versus High Dose Isotretinoin in Severe Acne Vulgaris Patients

Background: Oral isotretinoin is the recommended treatment for acne vulgaris, a skin disease especially common in teenagers and adolescents. This study was designed to compare the efficacy and safety of low dose with high dose isotretinoin in severe acne vulgaris patients.Material and Methods: This randomized controlled trial included 110 patients with a clinical diagnosis of acne vulgaris. They were divided into two groups. Both groups were matched for age (mean 18.2±3.7 vs 17.6±3.2 years), weight (mean 58±10.2 vs 60.7±9.3 Kg), gender and disease duration (3±1.1 vs 3±1.0 years). Group A received low dose oral isotretinoin (20 mg/day) while group B received standard high dose regimen (1mg/kg/day). All patients were followed up for 16 weeks to assess efficacy (assessment of complete remission) and safety (mucocutaneous side effects). All calculations were performed using SPSS v. 16 with p value &lt;0.05 considered as statistically significant.Results: There was no statistically significant difference in efficacy. However, significantly fewer mucocutaneous side effects were reported in group A (80%) as compared to group B (100%). This safety profile spectrum was observed across all pre-defined subsets i.e chielitis (78.1% vs 98.2%), dry skin (69.1% vs 92.7%), dry mouth (47.2% vs 72.7%) and facial rash (12.7% vs 30.9%).Conclusion: In patients with severe acne vulgaris, efficacy (complete remission) of low dose oral isotretinoin is almost equal to conventional high dose regimen but it is statistically superior in terms of safety (mucocutaneous side effects).

A Unilateral Facial Rash with Eye Involvement

A Unilateral Facial Rash with Eye Involvement

Młodzieńczy toczeń rumieniowaty układowy – opis przypadku

Juvenile systemic lupus erythematosus is an autoimmune, chronic, multisystemic inflammatory disease with an unknown etiology. The average age of juvenile systemic lupus erythematosus (jSLE) diagnosis is 11-14 years old, with a significant female predominance. Clinical manifestations of JSLE are extremely variable, from a relatively mild disease characterised by facial rash, joint pains, fever, fatigue, weight loss, alopecia and arthralgias to a severe life threatening illness.These and other symptoms of diffuse generalized inflammation including lymphadenopathy and hepatosplenomegaly occur both at onset and during disease flares.The authors present the case of a girl hospitalized in the Rheumatology Clinic due to fevers, skin lesions and haematological disorders. The diagnostic difficulty may have been the fact that the symptoms appear also in the course of many pediatric diseases. Finally, based on an in-depth medical history, physical examination and the results of immunological tests, they were recognized at the outset. Juvenile systemic lupus erythematosus is a disease with a diverse clinical picture, therefore, early diagnosis is not easy, but it is necessary to implement effective treatment. Knowledge and experience of the spectrum of paediatric and adolescent disease is important as well as recognition of when features merit further investigation.

Fabricated facial rash - an unusual presentation of factitious disorder.

Patients with factitious disorder typically present with signs or symptoms suggesting a medical problem, but which transpire to be self-induced or fabricated. Repeated investigations and treatments are often carried out to no avail before this possibility is considered. In this case, a 51-year-old female presented to the oral and maxillofacial surgery unit with toothache and a facial rash. Following admission to hospital a range of investigations were performed, and a tooth was extracted. Judicious attention by nursing staff led to the discovery that the patient had been applying make-up to mimic a skin rash. This concern was raised with the patient and she admitted falsifying the rash. Although this patient may have been experiencing pain, by applying make-up in this manner she sought to exaggerate the severity of her condition and as a result underwent potentially unnecessary procedures. This case provides a reminder that the possibility of factitious disorder should be considered in cases where patients present with symptoms or signs which appear fabricated or self-inflicted, defy anatomical or physiological principles, or do not correlate with the history. Thorough history taking is essential, and access to electronic care records may be informative. Psychiatric follow-up is recommended, but not all patients are willing to engage with this process.

Warfarin-induced unilateral facial swelling and skin rash

Allergic cutaneous reactions in patients on warfarin are rare and reported at an incidence of less than 0.1% in the literature.1 Nevertheless, various types of warfarin-induced cutaneous reactions have been...

PREOPERATIVE TREATMENT WITH METYRAPONE IN PATIENTS WITH CUSHING'S SYNDROME DUE TO ADRENAL ADENOMA.

ObjectiveMetyrapone has been approved for the treatment of patients with Cushing’s syndrome (CS), but only few retrospective clinical studies are available. The aim of our study was the prospective assessment of metyrapone as pre-operative treatment.Design and methodsBefore adrenalectomy, seven patients with ACTH-independent CS due to adrenal adenoma were prospectively treated with metyrapone for 3 months in three tertiary academic centers, with endocrine work-up and clinical evaluation at screening and at predefined evaluation time points (Days 14, 31, 48, 65, 82).ResultsIn all patients, UFC levels decreased up to normal range from baseline to Day 82 (609 (188–1476) vs 69 (28–152) nmol/24 h, P < 0.02), with a reduction of serum and salivary cortisol levels, and no significant increase of plasma ACTH and serum DHEAS levels. Clinical improvement was reported on quality of life (+16.7 (+4.2; +52.00) points, P < 0.04) and pressure control (systolic pressure, −25 (−52; −10) mmHg, P < 0.01; diastolic pressure, −16 (−50; +2 mmHg), P < 0.03). No significant change in weight, electrolytes, glycemic and lipid profile was reported. Although in women a significant increase of testosterone and androstenedione was reported, no worsening of clinical hyperandrogenism was observed. All drug-related adverse events (nausea, fatigue, low grade fever, edema of lower limbs and facial rash) were grade 1 or 2 and generally transient.ConclusionsThis prospective pilot study demonstrated that metyrapone is effective in normalizing biochemical and clinical parameters in patients with CS due to adrenal adenoma before surgical intervention, with minimal side effects.

Cutaneous Findings of Crimean-Congo Hemorrhagic Fever: a Study of 269 Cases.

Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic viral disease. We aimed to investigate the cutaneous manifestations of CCHF and reveal their associations with fatality. Two hundred and sixty-nine patients diagnosed with CCHF were assessed. Skin findings were observed in 170 (63.2%) patients. A facial rash was the most common cutaneous finding (n = 82, 30.5%). In severe cases, hemorrhagic cutaneous manifestations (petechiae and ecchymoses) were recognized. A statistically significant correlation was obtained between cutaneous manifestations and fatality, and it was determined that there was a strong positive correlation between fatality and ecchymosis (r = 567, p < 0.001). In addition, a logistic regression analysis was performed, and death occurred 4.69 times more in those with skin signs than in those without. We hypothesize that CCHF patients with ecchymosis are at the highest risk and that cutaneous findings can contribute to the prognosis of CCHF.