Clinical Characteristics Associated With Severe Misdiagnosis of Scabies: A Retrospective Hospital-Based Study

Clinical Characteristics Associated With Severe Misdiagnosis of Scabies: A Retrospective Hospital-Based Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Characteristics Associated With Severe Misdiagnosis of Scabies: A Retrospective Hospital-Based Study Tian Wang, Lu Tang, Lanhai Zhong, Jiande Han, Naiyu Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9269090/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Severe misdiagnosis of scabies can result in prolonged symptoms, inappropriate use of immunosuppressive therapy, secondary infections, and transmission within an institution. Hospitalized patients frequently present with atypical morphology or distribution, leading to uncertainty in diagnosis. Misdiagnosis of scabies among hospitalized patients remains poorly characterized. Objective This study seeks to identify clinical characteristics associated with severe misdiagnosis of scabies, using a severity-based grading system. Methods We performed a retrospective review of 41 patients admitted to the hospital and subsequently confirmed to have scabies. The severity of misdiagnosis was graded from level 0 to level 3, with levels 2 and 3 defined as severe misdiagnosis. Univariate logistic regression was performed to assess potential predictors of severe misdiagnosis, whereas univariate ordinal logistic regression (proportional odds model) was performed to assess potential predictors across the entire severity grading system (levels 0 to 3). Results 10 severe scabies misdiagnoses (24.4%) were identified among the 41 patients. Severe misdiagnosis was protected against when interdigital involvement was present, with an OR of 0.048 (95% CI 0.008–0.297; P = 0.001). Severe misdiagnosis was more likely to occur if there was generalized involvement, with an OR of 7.27 (95% CI 1.31–40.42; P = 0.023). Ordinal regression analysis confirmed these findings: generalized involvement was associated with a significant increase in OR (14.74; P = 0.002), while interdigital involvement was associated with a significant decrease in OR (0.106; P = 0.003). There appeared to be a trend toward increased severity of misdiagnosis as age increased. Routine laboratory tests were poor predictors of severe misdiagnosis. Conclusions In hospitalized patients with scabies, severe misdiagnosis is strongly associated with the absence of classical interdigital involvement and presence of generalized distribution. Although not statistically significant, blistering or bullous lesions may also mislead the diagnosis of scabies. Targeted examination of classic sites or empirical treatment when a diagnosis is suspected remains crucial, especially in cases of widespread or atypical presentations. scabies misdiagnosis diagnostic error interdigital generalized eruption Figures Figure 1 Figure 2 Figure 3 Introduction Scabies is a contagious ectoparasitic infestation caused by Sarcoptes scabiei var. hominis and remains a frequent cause of pruritic skin disease in both community and hospital settings. Most previous studies focused on community cases. Classic scabies presents with intense pruritus, often worse at night, and lesions at typical sites such as the interdigital webs, wrists, axillae, and genital area [1] . Even so, scabies is still commonly misdiagnosed, particularly among hospitalized patients, where rashes are often multifactorial and clinical features may be atypical [2] . Diagnostic errors in scabies carry important consequences. Delayed recognition can postpone appropriate treatment, prolong symptoms, and allow continued transmission. In some cases, patients receive topical or systemic corticosteroids or other immunosuppressants for extended periods, which may increase the risk of secondary infection and aggravate more severe forms of the disease [3] . In hospital wards, unrecognized cases may lead to outbreaks and increased infection-control workload. Previous studies have usually assessed misdiagnosis in binary terms or examined time to correct diagnosis [4] . In practice, however, diagnostic error is not uniform. Some patients experience only brief delays, while others undergo weeks of inappropriate treatment with potential harm. Recognizing this spectrum may provide a more clinically meaningful understanding of misdiagnosis. In daily practice, clinicians often rely on pattern recognition: typical findings such as interdigital burrows raise suspicion of scabies, whereas their absence may lead to alternative diagnoses. In the present study, we used a predefined grading system (Levels 0–3) to categorize misdiagnosis in a hospital-based cohort of confirmed scabies cases. Severe misdiagnosis (Levels 2–3) was analyzed as a clinically relevant outcome, and ordinal regression was applied to explore factors associated with increasing misdiagnosis severity. We hypothesized that anatomical distribution patterns—especially interdigital involvement and generalized rash—would be more strongly associated with severe misdiagnosis than routine laboratory findings in hospitalized patients. Methods 1. Study design and setting We performed a retrospective review of hospitalized patients diagnosed with scabies at the First Affiliated Hospital of Sun Yat-sen University, a tertiary care center, over a 10-year period. Clinical information was retrieved from electronic medical records. The study was approved by the ethics committee (IIT-2026-196). 2. Participants and case confirmation Patients were included if scabies was confirmed by either microscopic identification of mites, eggs, or fecal pellets in skin scrapings, or histology findings (Figure 1), or by an experienced dermatologist’s clinical diagnosis supported by compatible features and clinical response to anti-scabietic treatment. Cases lacking sufficient information to determine misdiagnosis grade were excluded. 3. Misdiagnosis severity grading To better describe differences in diagnostic timing and management, we developed a four-level grading system defined for this study, with reference to the IACS 2020 criteria and previous reports on diagnostic delay and treatment-related modification of scabies [5] . Case evaluation was performed independently by two dermatologists. Discrepancies were resolved through consultation with a senior professor. Severe misdiagnosis was defined as Levels 2–3. Level 0 (timely diagnosis) referred to cases in which scabies was considered at the first visit or treatment was initiated within 7 days. Level 1 (delayed diagnosis) indicated delayed diagnosis, defined as confirmation and initiation of anti-scabies therapy at least 14 days after the first visit, with alternative diagnoses initially favored [4] . Level 2 (incorrect treatment) described an inappropriate treatment course prior to scabies-directed therapy, including management as eczema, dermatitis, or urticaria, or use of systemic corticosteroids or immunosuppressants without anti-scabies treatment [6] . Level 3 (severe misdiagnosis) represented severe misdiagnosis or mismanagement, characterized by prolonged immunosuppressive exposure and/or major complications such as secondary infection or hospitalization [7] . 4. Variables Demographic variables included age and sex. Host factors comprised age >65 years or <14 years, immunosuppression, bedridden status, and coexisting skin diseases. Conditions considered indicative of immunosuppression included the presence of HIV infection, long-term use of systemic corticosteroids or other immunosuppressive agents, ongoing biologic therapy, severe systemic infection, or active malignancy. Involved sites were documented as interdigital or axillary areas, the trunk, limbs, the genital region, or a generalized distribution. Based on lesion morphology, scabies was categorized into four subtypes (nodular, bullous, crusted, and eczematous) (Figure 2). In addition, whether the clinical presentation could be recognized as typical scabies was assessed separately. White blood cell count (WBC), absolute eosinophil count, eosinophil percentage, and serum IgE were collected at the first visit when available. Eosinophil percentage was classified using 8% as the cut-off, and IgE was categorized as >120 IU/mL or ≤120 IU/mL. 5. Statistical analysis Continuous variables are expressed as mean ± standard deviation, and categorical variables as counts with percentages. To explore factors associated with misdiagnosis severity, we performed univariate logistic regression for severe misdiagnosis (Levels 2–3 vs 0–1), reporting odds ratios (ORs) with 95% confidence intervals (CIs). We also used ordinal logistic regression (proportional odds model) to assess associations across the full range of misdiagnosis grades (Levels 0–3). Analyses were based on complete cases. For exploratory evaluation of scraping positivity by anatomical site, Fisher’s exact test was applied because of small cell counts. A two-sided P value <0.05 was considered statistically significant. Results 1. Baseline characteristics Forty-one hospitalized patients with confirmed scabies were included (Table 1 ). The mean age was 60.2 ± 22.8 years, and most patients were male (26/41, 63.4%). Twenty-one (51.2%) were older than 65 years. Immunosuppression was documented in 13 patients (31.7%), and over half were bedridden (24/41, 58.5%). Eight patients (19.5%) had underlying dermatoses. Interdigital involvement was observed in 28 patients (68.3%), and 19 (46.3%) presented with generalized distribution. According to the predefined grading system, 27 patients (65.9%) were classified as Level 0, 4 (9.8%) as Level 1, 9 (22.0%) as Level 2, and 1 (2.4%) as Level 3. Severe misdiagnosis (Levels 2–3) was identified in 10 of 41 patients (24.4%). Table 1 Baseline characteristics Characteristic Value Total patients 41 Age, mean ± SD (years) 60.2 ± 22.8 Male, n (%) 26 (63.4%) Age > 65 years, n (%) 21 (51.2%) Immunosuppressed, n (%) 13 (31.7%) Bedridden, n (%) 24 (58.5%) Underlying dermatosis, n (%) 8 (19.5%) Interdigital involvement, n (%) 28 (68.3%) Generalized involvement, n (%) 19 (46.3%) Trunk involvement, n (%) 33 (80.5%) Extremities involvement, n (%) 36 (87.8%) Genital involvement, n (%) 16 (39.0%) Misdiagnosis in bullous type, n (%) 3 (60%) Misdiagnosis in crusted type, n (%) 2 (28.6%) Misdiagnosis in eczematous type, n (%) 7 (36.8%) Misdiagnosis in nodular type, n (%) 2 (20%) Misdiagnosis Level 0, n (%) 27 (65.9%) Misdiagnosis Level 1, n (%) 4 (9.8%) Misdiagnosis Level 2, n (%) 9 (22.0%) Misdiagnosis Level 3, n (%) 1 (2.4%) SD: Standard deviation. : 2. Misdiagnosis grade distribution by different factors Among atypical morphological subtypes, the distribution of misdiagnosis grades differed (Fig. 3 ). Bullous scabies showed the highest proportion of higher-grade misdiagnosis, whereas nodular and crusted forms were predominantly diagnosed at Level 0. Eczematous morphology demonstrated an intermediate distribution. Misdiagnosis grades differed markedly by interdigital involvement (Fig. 3 ). Patients with interdigital involvement were predominantly diagnosed at Level 0, whereas those without interdigital involvement exhibited a higher proportion of Level 2–3 misdiagnosis. 3. Predictors of severe misdiagnosis In univariate logistic regression (Table 2 ), interdigital involvement was strongly protective against severe misdiagnosis (OR 0.048, 95% CI 0.008–0.297; P = 0.001). Generalized involvement was associated with increased odds of severe misdiagnosis (OR 7.27, 95% CI 1.31–40.42; P = 0.023). Age showed a trend toward association with severe misdiagnosis (OR 1.06 per year, 95% CI 0.996–1.134; P = 0.068). IgE > 120 IU/mL showed a non-significant trend (OR 3.23; P = 0.133). Table 2 Univariate logistic regression for severe misdiagnosis (Level 2–3) Predictor OR 95% CI P value Interdigital involvement 0.048 0.008–0.297 0.001 Generalized involvement 7.273 1.308–40.424 0.023 Age (per year) increase se) 1.062 0.996–1.134 0.068 IgE > 120 IU/mL 3.231 0.700–14.907 0.133 4. Ordinal regression across the misdiagnosis spectrum Ordinal logistic regression supported the same directional findings across the full misdiagnosis grade spectrum (Table 3 ). Interdigital involvement was associated with lower misdiagnosis grade (common OR 0.106; P = 0.003), whereas generalized involvement strongly increased the odds of being graded in a higher misdiagnosis category (common OR 14.74; P = 0.002). Age again showed a trend ( P = 0.062). Bullous morphology (among atypical forms) trended toward higher misdiagnosis grades but did not reach statistical significance in the proportional odds model. Table 3 Univariate ordinal logistic regression for misdiagnosis grade (Level 0–3) Predictor Common OR 95% CI P value Interdigital involvement 0.106 0.024–0.458 0.003 Generalized involvement 14.736 2.702–80.361 0.002 Age (per year increase) 1.038 0.998–1.080 0.062 IgE > 120 IU/mL 2.834 0.762–10.540 0.120 Bullous morphology (vs. other morphologies) 3.970 0.642–24.553 0.138 5. Exploratory analysis of scraping positivity An exploratory analysis restricted to laboratory-confirmed cases ( n = 34) suggested a lower proportion of severe misdiagnosis among patients with interdigital scraping positivity (0/11) compared with those without (6/23). However, this did not reach statistical significance (Fisher exact P = 0.145). Discussion Scabies may resemble a range of other conditions, including onychomycosis [8] , blistering disorders [9, 10] , eczema, and nodular prurigo. This is particularly true in hospitalized patients, where atypical presentations often contribute to delayed diagnosis or misdiagnosis. In this inpatient cohort, about one quarter of patients had severe misdiagnosis. Because the number of severe misdiagnosis events was limited ( n = 10), multivariable regression was not performed to avoid overfitting and unstable estimates (events-per-variable < 10). This decision was made to preserve statistical validity and model interpretability. According to our results, two clinical features were most closely tied to diagnostic error: absence of interdigital involvement and generalized distribution. Laboratory markers were not helpful in separating severe misdiagnosis from other cases. To our knowledge, few studies have attempted to quantify misdiagnosis severity using a structured grading system. Interdigital involvement remains one of the classic sites examined when scabies is suspected, and predilection-site inspection is emphasized in current diagnostic guidance [5] . In our cohort, interdigital lesions often coincided with earlier recognition, whereas their absence was associated with delayed or incorrect management. In hospitalized patients—where drug eruptions and eczematous dermatitis are common—lack of interdigital findings may lower clinical suspicion for scabies. Generalized rash was linked to more severe misdiagnosis. In practice, diffuse pruritic eruptions in inpatients are frequently attributed to medications or systemic illness, and scabies may not be considered first. Extensive excoriation can also obscure burrows and other subtle signs. In older or institutionalized populations, atypical or generalized presentations have been reported and can contribute to delayed recognition [11] . Bullous presentations tended to be associated with higher misdiagnosis severity, which is consistent with prior reports that bullous scabies can mimic autoimmune blistering disease [12] . Several studies have described an overlap between scabies and bullous pemphigoid (BP) [13] , and cases of concurrent BP and scabies have been reported [14] . In our retrospective cohort, five patients were defined as bullous scabies. Among them, two severe misdiagnosed cases showed histopathological and immunofluorescence findings consistent with BP. However, both patients failed to improve with immunosuppressive therapy and subsequently developed new blisters. Scabies was eventually confirmed by scraping test. Although negative immunofluorescence generally favors a diagnosis of non-autoimmune diseases, a systematic literature review revealed that 19 out of 33 patients with bullous scabies (58%) had positive direct immunofluorescence, and 5 out of 24 evaluated (21%) had positive indirect immunofluorescence on serological testing [15] . This indicates that scabies may cause an immunological response, the cause of which is unclear. Some researchers have suggested that the mites or their products may cause alterations or the release of BP antigen, as seen in BP, leading to an autoimmune reaction, and resulting in the production of anti-basement membrane zone antibodies. Another possibility is that the mite itself may act as an antigen that cross-reacts with the BP antigen to induce the production of autoantibodies [16] . Older age also showed a trend toward greater misdiagnosis severity; atypical presentations in older adults have been discussed in the literature [17] . In contrast, routine laboratory parameters (WBC, eosinophil measures) were not discriminative in our dataset, and IgE offered limited additional value. These results raise some practical concerns. Our findings highlight the importance of careful examination of classical scabies sites even in atypical hospital presentations. Scabies should not be excluded simply because interdigital lesions are absent. In hospitalized patients with generalized pruritic eruptions, careful inspection of typical sites remains important, and confirmatory testing should be considered. When clinical suspicion for scabies remains high despite negative initial tests, a trial of empirical anti-scabietic treatment can be considered. If scabies has not been adequately ruled out, the necessity of long-term use of corticosteroids or immunosuppressants for suspected inflammatory skin conditions should be reassessed. This study was retrospective and conducted at a single center, with a relatively small number of hospitalized patients. Because the data were collected from medical records, some clinical details were incomplete. The limited number of severe misdiagnosis cases also meant that multivariable analysis was not feasible. In addition, misdiagnosis in scabies is influenced by clinical context and physician experience, which means it is difficult to conduct a prospective study. Further multicenter studies may help determine whether these findings are reproducible and applicable to broader patient populations. Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Medical Ethics Committee of the First Affiliated Hospital, Sun Yat-sen University (IIT-2026-196). Consent for publication Informed consent for publication was obtained from the participant (the patient) in this study. A detailed and through explanation has been given before receiving the consent to publish this case report including relevant information like pictures and clinical data. Availability of data and materials The datasets used or analyzed in this study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding No funding. Authors' contributions TW and LT contributed equally to this work. TW conceived the study and drafted the initial manuscript. LT contributed to data collection and manuscript drafting. LHZ participated in the data collection. JDH was responsible for project administration and supervision. NYL reviewed and edit the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Tarbox M, Walker K, Tan M. Scabies. JAMA. 2018;320(6):612. Uygun A, Albayrak C, Özgen Ü, Kartal İ, Dinçer OS, Kangal Şimşek H, et al. Scabies outbreak in paediatric malignancy patients: clinical and healthcare burden. J Hosp Infect. 2026;168:58-63. Thomas C, Coates SJ, Engelman D, Chosidow O, Chang AY. Ectoparasites: Scabies. J Am Acad Dermatol. 2020;82(3):533-548. Betlloch-Mas I, Boluda-Verdú E, Jara-Rico N, Sánchez-García V, Berbegal-De Gracia L, Chiner-Vives E. Scabies in Infants: Series of 51 Cases. Children. 2024;11(4):443. Engelman D, Yoshizumi J, Hay RJ, Osti M, Micali G, Norton S, et al. The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies. Br J Dermatol. 2020;183(5):808-820. Hengge UR, Currie BJ, Jäger G, Lupi O, Schwartz RA. Scabies: a ubiquitous neglected skin disease. Lancet Infect Dis. 2006;6(12):769-779. Morrison EJ, Middleton J, Lanza S, Cowen JE, Hewitt K, Walker SL, et al. Do we know how scabies outbreaks in residential and nursing care homes for the elderly should be managed? A systematic review of interventions using a novel approach to assess evidence quality. Epidemiol Infect. 2019;147:e250. Zou Y, Hu W, Zheng J, Pan M. Nail infestation: an atypical presentation of typical scabies. Lancet. 2018;391(10136):2272. Li LY, Sun H, Li XY, Liu JH, Liu WX, Luo DQ. Hemorrhagic bulla: a rare presentation of scabies. Ann Transl Med. 2019;7(5):107. Bhawan J, Milstone E, Malhotra R, Rosenfeld T, Appel M. Scabies presenting as bullous pemphigoid-like eruption. J Am Acad Dermatol. 1991;24(2 Pt 1):179-181. Wilson MM, Philpott CD, Breer WA. Atypical presentation of scabies among nursing home residents. J Gerontol A Biol Sci Med Sci. 2001;56(7):M424-M427. Luo DQ, Huang MX, Liu JH, Tang W, Zhao YK, Sarkar R, Tang W, Huang MX. Bullous Scabies. Am J Trop Med Hyg. 2016;95(3):689-693. Rozenblat M, Halaj A, Levi A, Lapidoth M, Ziv M. Bullous Pemphigoid and Scabies: Is There an Association?. J Drugs Dermatol. 2022;21(9):1009-1011. Ran D, Bao F, Du D. Unique Scabies Presentation in a Patient with Bullous Pemphigoid. Am J Trop Med Hyg. 2024;111(3):455-456. Lima PB, Florêncio LC, Merlotto MR, Miot HA. Vesiculobullous scabies: an atypical manifestation in an adult. Int J Dermatol. 2020;59(11):e407-e408. Talaga-Ćwiertnia K. Sarcoptes Infestation. What Is Already Known, and What Is New about Scabies at the Beginning of the Third Decade of the 21st Century? Pathogens. 2021;10(7):868. Hamm H, Stoevesandt J, Sunderkötter C. Skabies im Alter [Scabies in old age]. Z Gerontol Geriatr. 2019;52(8):795-807. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9269090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634615472,"identity":"fe447ad3-b51e-4548-8e28-4465af1afd98","order_by":0,"name":"Tian Wang","email":"","orcid":"","institution":"First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Tian","middleName":"","lastName":"Wang","suffix":""},{"id":634615476,"identity":"547a8b93-a4ad-448c-aa67-c670930e4795","order_by":1,"name":"Lu Tang","email":"","orcid":"","institution":"First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Tang","suffix":""},{"id":634615490,"identity":"fb52d178-360c-4755-94b9-0cb56722dbe8","order_by":2,"name":"Lanhai Zhong","email":"","orcid":"","institution":"First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Lanhai","middleName":"","lastName":"Zhong","suffix":""},{"id":634615491,"identity":"d2f62494-e01a-469d-9a00-576912b30792","order_by":3,"name":"Jiande Han","email":"","orcid":"","institution":"First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Jiande","middleName":"","lastName":"Han","suffix":""},{"id":634615492,"identity":"8683f615-228e-4577-8567-d3e3c5052409","order_by":4,"name":"Naiyu Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYBACPmYQWcHAwMYOF0vAr4UNrOUMjEGUFhDB2AYkiNfCznvsMe+8bfJAFzJ/5vlzmIGfPceA4ecOfA7jSzfm3XbbsI2ZgU2at+0wg2TPGwPG3jP4tPCYSQO1MIK0MPM2HGYwuJFjwAx2Kl4tc27bt8EcZk+clobbiUAtDNI8bEBbJIjQIjnn2O3kNqAyyblt6TwSZ54VHOzFo4Wf/4yZxJua27bz25sPf3jzx1qOvz1544OfeLSAABMPmGJsADHA7AP4NQDV/kBnjIJRMApGwShABgC8qUCd+HtcwgAAAABJRU5ErkJggg==","orcid":"","institution":"First Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"prefix":"","firstName":"Naiyu","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2026-03-30 15:25:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9269090/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9269090/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108941836,"identity":"21064552-71c7-4c0d-9561-28ca6380a255","added_by":"auto","created_at":"2026-05-11 05:38:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":925196,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Fluorescent microscopy showing scabies eggshell; (B) Fluorescent microscopy showing a Sarcoptes scabiei mite with an egg; (C) Skin scraping showing Sarcoptes scabiei mite. (D) Histopathological images showing a mite in the stratum corneum and mixed-cell infiltration in the dermis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9269090/v1/ac8232380569cb62cbb69bf7.png"},{"id":108941876,"identity":"1d2b78c2-c958-4ad1-9e52-5bfe8e4bc4fe","added_by":"auto","created_at":"2026-05-11 05:38:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":835400,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(A) Bullous type; (B)Eczematous type;(C) Crusted type; (D)Nodular type.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9269090/v1/4b0c17869f9e2afc9eac76c4.png"},{"id":108941875,"identity":"077ebc74-02a9-47cd-ba80-a5f7ace89fc1","added_by":"auto","created_at":"2026-05-11 05:38:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41790,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Misdiagnosis Grades According to Atypical Morphological Subtype and Interdigital Involvement.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9269090/v1/832049e3fc66ea7f55a078de.png"},{"id":108942324,"identity":"145bb498-6b01-41dd-ac46-e5d9bd39296d","added_by":"auto","created_at":"2026-05-11 05:40:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2563052,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9269090/v1/003e308a-bbff-4e55-8929-702237e89c63.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Characteristics Associated With Severe Misdiagnosis of Scabies: A Retrospective Hospital-Based Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eScabies is a contagious ectoparasitic infestation caused by Sarcoptes scabiei var. hominis and remains a frequent cause of pruritic skin disease in both community and hospital settings. Most previous studies focused on community cases. Classic scabies presents with intense pruritus, often worse at night, and lesions at typical sites such as the interdigital webs, wrists, axillae, and genital area\u003csup\u003e[1]\u003c/sup\u003e. Even so, scabies is still commonly misdiagnosed, particularly among hospitalized patients, where rashes are often multifactorial and clinical features may be atypical\u003csup\u003e[2]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDiagnostic errors in scabies carry important consequences. Delayed recognition can postpone appropriate treatment, prolong symptoms, and allow continued transmission. In some cases, patients receive topical or systemic corticosteroids or other immunosuppressants for extended periods, which may increase the risk of secondary infection and aggravate more severe forms of the disease\u003csup\u003e[3]\u003c/sup\u003e. In hospital wards, unrecognized cases may lead to outbreaks and increased infection-control workload.\u003c/p\u003e \u003cp\u003ePrevious studies have usually assessed misdiagnosis in binary terms or examined time to correct diagnosis\u003csup\u003e[4]\u003c/sup\u003e. In practice, however, diagnostic error is not uniform. Some patients experience only brief delays, while others undergo weeks of inappropriate treatment with potential harm. Recognizing this spectrum may provide a more clinically meaningful understanding of misdiagnosis. In daily practice, clinicians often rely on pattern recognition: typical findings such as interdigital burrows raise suspicion of scabies, whereas their absence may lead to alternative diagnoses.\u003c/p\u003e \u003cp\u003eIn the present study, we used a predefined grading system (Levels 0–3) to categorize misdiagnosis in a hospital-based cohort of confirmed scabies cases. Severe misdiagnosis (Levels 2–3) was analyzed as a clinically relevant outcome, and ordinal regression was applied to explore factors associated with increasing misdiagnosis severity. We hypothesized that anatomical distribution patterns—especially interdigital involvement and generalized rash—would be more strongly associated with severe misdiagnosis than routine laboratory findings in hospitalized patients.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e1. Study design and setting\u003c/p\u003e\n\u003cp\u003eWe performed a retrospective review of hospitalized patients diagnosed with scabies at the First Affiliated Hospital of Sun Yat-sen University, a tertiary care center, over a 10-year period. Clinical information was retrieved from electronic medical records. The study was approved by the ethics committee (IIT-2026-196).\u003c/p\u003e\n\u003cp\u003e2. Participants and case confirmation\u003c/p\u003e\n\u003cp\u003ePatients were included if scabies was confirmed by either microscopic identification of mites, eggs, or fecal pellets in skin scrapings, or histology findings (Figure 1), or by an experienced dermatologist\u0026rsquo;s clinical diagnosis supported by compatible features and clinical response to anti-scabietic treatment. Cases lacking sufficient information to determine misdiagnosis grade were excluded.\u003c/p\u003e\n\u003cp\u003e3. Misdiagnosis severity grading\u003c/p\u003e\n\u003cp\u003eTo better describe differences in diagnostic timing and management, we developed a four-level grading system defined for this study, with reference to the IACS 2020 criteria and previous reports on diagnostic delay and treatment-related modification of scabies\u003csup\u003e[5]\u003c/sup\u003e. Case evaluation was performed independently by two dermatologists. Discrepancies were resolved through consultation with a senior professor. Severe misdiagnosis was defined as Levels 2\u0026ndash;3.\u003c/p\u003e\n\u003cp\u003eLevel 0 (timely diagnosis) referred to cases in which scabies was considered at the first visit or treatment was initiated within 7 days.\u003c/p\u003e\n\u003cp\u003eLevel 1 (delayed diagnosis) indicated delayed diagnosis, defined as confirmation and initiation of anti-scabies therapy at least 14 days after the first visit, with alternative diagnoses initially favored\u003csup\u003e[4]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eLevel 2 (incorrect treatment) described an inappropriate treatment course prior to scabies-directed therapy, including management as eczema, dermatitis, or urticaria, or use of systemic corticosteroids or immunosuppressants without anti-scabies treatment\u003csup\u003e[6]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eLevel 3 (severe misdiagnosis) represented severe misdiagnosis or mismanagement, characterized by prolonged immunosuppressive exposure and/or major complications such as secondary infection or hospitalization\u003csup\u003e[7]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e4. Variables\u003c/p\u003e\n\u003cp\u003eDemographic variables included age and sex. Host factors comprised age \u0026gt;65 years or \u0026lt;14 years, immunosuppression, bedridden status, and coexisting skin diseases. Conditions considered indicative of immunosuppression included the presence of HIV infection, long-term use of systemic corticosteroids or other immunosuppressive agents, ongoing biologic therapy, severe systemic infection, or active malignancy. Involved sites were documented as interdigital or axillary areas, the trunk, limbs, the genital region, or a generalized distribution. Based on lesion morphology, scabies was categorized into four subtypes (nodular, bullous, crusted, and eczematous) (Figure 2). In addition, whether the clinical presentation could be recognized as typical scabies was assessed separately. White blood cell count (WBC), absolute eosinophil count, eosinophil percentage, and serum IgE were collected at the first visit when available. Eosinophil percentage was classified using 8% as the cut-off, and IgE was categorized as \u0026gt;120 IU/mL or \u0026le;120 IU/mL.\u003c/p\u003e\n\u003cp\u003e5. Statistical analysis\u003c/p\u003e\n\u003cp\u003eContinuous variables are expressed as mean \u0026plusmn; standard deviation, and categorical variables as counts with percentages. To explore factors associated with misdiagnosis severity, we performed univariate logistic regression for severe misdiagnosis (Levels 2\u0026ndash;3 vs 0\u0026ndash;1), reporting odds ratios (ORs) with 95% confidence intervals (CIs). We also used ordinal logistic regression (proportional odds model) to assess associations across the full range of misdiagnosis grades (Levels 0\u0026ndash;3). Analyses were based on complete cases. For exploratory evaluation of scraping positivity by anatomical site, Fisher\u0026rsquo;s exact test was applied because of small cell counts. A two-sided P value \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Baseline characteristics\u003c/h3\u003e\n\u003cp\u003eForty-one hospitalized patients with confirmed scabies were included (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean age was 60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;22.8 years, and most patients were male (26/41, 63.4%). Twenty-one (51.2%) were older than 65 years. Immunosuppression was documented in 13 patients (31.7%), and over half were bedridden (24/41, 58.5%). Eight patients (19.5%) had underlying dermatoses. Interdigital involvement was observed in 28 patients (68.3%), and 19 (46.3%) presented with generalized distribution. According to the predefined grading system, 27 patients (65.9%) were classified as Level 0, 4 (9.8%) as Level 1, 9 (22.0%) as Level 2, and 1 (2.4%) as Level 3. Severe misdiagnosis (Levels 2\u0026ndash;3) was identified in 10 of 41 patients (24.4%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.2\u0026thinsp;\u0026plusmn;\u0026thinsp;22.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (63.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;65 years, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (51.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImmunosuppressed, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (31.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBedridden, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (58.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderlying dermatosis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (19.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterdigital involvement, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (68.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized involvement, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (46.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrunk involvement, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (80.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtremities involvement, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (87.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenital involvement, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (39.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis in bullous type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis in crusted type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis in eczematous type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (36.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis in nodular type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis Level 0, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (65.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis Level 1, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis Level 2, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisdiagnosis Level 3, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSD: Standard deviation.\u003c/p\u003e \u003cp\u003e:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e2. Misdiagnosis grade distribution by different factors\u003c/h3\u003e\n\u003cp\u003eAmong atypical morphological subtypes, the distribution of misdiagnosis grades differed (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Bullous scabies showed the highest proportion of higher-grade misdiagnosis, whereas nodular and crusted forms were predominantly diagnosed at Level 0. Eczematous morphology demonstrated an intermediate distribution.\u003c/p\u003e \u003cp\u003eMisdiagnosis grades differed markedly by interdigital involvement (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Patients with interdigital involvement were predominantly diagnosed at Level 0, whereas those without interdigital involvement exhibited a higher proportion of Level 2\u0026ndash;3 misdiagnosis.\u003c/p\u003e\n\u003ch3\u003e3. Predictors of severe misdiagnosis\u003c/h3\u003e\n\u003cp\u003eIn univariate logistic regression (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), interdigital involvement was strongly protective against severe misdiagnosis (OR 0.048, 95% CI 0.008\u0026ndash;0.297; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Generalized involvement was associated with increased odds of severe misdiagnosis (OR 7.27, 95% CI 1.31\u0026ndash;40.42; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.023). Age showed a trend toward association with severe misdiagnosis (OR 1.06 per year, 95% CI 0.996\u0026ndash;1.134; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.068). IgE\u0026thinsp;\u0026gt;\u0026thinsp;120 IU/mL showed a non-significant trend (OR 3.23; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.133).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate logistic regression for severe misdiagnosis (Level 2\u0026ndash;3)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterdigital involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.008\u0026ndash;0.297\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.308\u0026ndash;40.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (per year) increase\u003c/p\u003e \u003cp\u003ese)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.996\u0026ndash;1.134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIgE\u0026thinsp;\u0026gt;\u0026thinsp;120 IU/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.700\u0026ndash;14.907\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e4. Ordinal regression across the misdiagnosis spectrum\u003c/h3\u003e\n\u003cp\u003eOrdinal logistic regression supported the same directional findings across the full misdiagnosis grade spectrum (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Interdigital involvement was associated with lower misdiagnosis grade (common OR 0.106; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003), whereas generalized involvement strongly increased the odds of being graded in a higher misdiagnosis category (common OR 14.74; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Age again showed a trend (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.062). Bullous morphology (among atypical forms) trended toward higher misdiagnosis grades but did not reach statistical significance in the proportional odds model.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate ordinal logistic regression for misdiagnosis grade (Level 0\u0026ndash;3)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommon OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterdigital involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.024\u0026ndash;0.458\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneralized involvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.736\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.702\u0026ndash;80.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (per year increase)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.998\u0026ndash;1.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIgE\u0026thinsp;\u0026gt;\u0026thinsp;120 IU/mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.834\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.762\u0026ndash;10.540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.120\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBullous morphology (vs. other morphologies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.642\u0026ndash;24.553\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e5. Exploratory analysis of scraping positivity\u003c/h3\u003e\n\u003cp\u003eAn exploratory analysis restricted to laboratory-confirmed cases (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;34) suggested a lower proportion of severe misdiagnosis among patients with interdigital scraping positivity (0/11) compared with those without (6/23). However, this did not reach statistical significance (Fisher exact \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.145).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eScabies may resemble a range of other conditions, including onychomycosis\u003csup\u003e[8]\u003c/sup\u003e, blistering disorders\u003csup\u003e[9, 10]\u003c/sup\u003e, eczema, and nodular prurigo. This is particularly true in hospitalized patients, where atypical presentations often contribute to delayed diagnosis or misdiagnosis. In this inpatient cohort, about one quarter of patients had severe misdiagnosis. Because the number of severe misdiagnosis events was limited (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10), multivariable regression was not performed to avoid overfitting and unstable estimates (events-per-variable\u0026thinsp;\u0026lt;\u0026thinsp;10). This decision was made to preserve statistical validity and model interpretability. According to our results, two clinical features were most closely tied to diagnostic error: absence of interdigital involvement and generalized distribution. Laboratory markers were not helpful in separating severe misdiagnosis from other cases. To our knowledge, few studies have attempted to quantify misdiagnosis severity using a structured grading system.\u003c/p\u003e \u003cp\u003eInterdigital involvement remains one of the classic sites examined when scabies is suspected, and predilection-site inspection is emphasized in current diagnostic guidance\u003csup\u003e[5]\u003c/sup\u003e. In our cohort, interdigital lesions often coincided with earlier recognition, whereas their absence was associated with delayed or incorrect management. In hospitalized patients\u0026mdash;where drug eruptions and eczematous dermatitis are common\u0026mdash;lack of interdigital findings may lower clinical suspicion for scabies. Generalized rash was linked to more severe misdiagnosis. In practice, diffuse pruritic eruptions in inpatients are frequently attributed to medications or systemic illness, and scabies may not be considered first. Extensive excoriation can also obscure burrows and other subtle signs. In older or institutionalized populations, atypical or generalized presentations have been reported and can contribute to delayed recognition\u003csup\u003e[11]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBullous presentations tended to be associated with higher misdiagnosis severity, which is consistent with prior reports that bullous scabies can mimic autoimmune blistering disease\u003csup\u003e[12]\u003c/sup\u003e. Several studies have described an overlap between scabies and bullous pemphigoid (BP)\u003csup\u003e[13]\u003c/sup\u003e, and cases of concurrent BP and scabies have been reported\u003csup\u003e[14]\u003c/sup\u003e. In our retrospective cohort, five patients were defined as bullous scabies. Among them, two severe misdiagnosed cases showed histopathological and immunofluorescence findings consistent with BP. However, both patients failed to improve with immunosuppressive therapy and subsequently developed new blisters. Scabies was eventually confirmed by scraping test. Although negative immunofluorescence generally favors a diagnosis of non-autoimmune diseases, a systematic literature review revealed that 19 out of 33 patients with bullous scabies (58%) had positive direct immunofluorescence, and 5 out of 24 evaluated (21%) had positive indirect immunofluorescence on serological testing\u003csup\u003e[15]\u003c/sup\u003e. This indicates that scabies may cause an immunological response, the cause of which is unclear. Some researchers have suggested that the mites or their products may cause alterations or the release of BP antigen, as seen in BP, leading to an autoimmune reaction, and resulting in the production of anti-basement membrane zone antibodies. Another possibility is that the mite itself may act as an antigen that cross-reacts with the BP antigen to induce the production of autoantibodies\u003csup\u003e[16]\u003c/sup\u003e. Older age also showed a trend toward greater misdiagnosis severity; atypical presentations in older adults have been discussed in the literature\u003csup\u003e[17]\u003c/sup\u003e. In contrast, routine laboratory parameters (WBC, eosinophil measures) were not discriminative in our dataset, and IgE offered limited additional value.\u003c/p\u003e \u003cp\u003eThese results raise some practical concerns. Our findings highlight the importance of careful examination of classical scabies sites even in atypical hospital presentations. Scabies should not be excluded simply because interdigital lesions are absent. In hospitalized patients with generalized pruritic eruptions, careful inspection of typical sites remains important, and confirmatory testing should be considered. When clinical suspicion for scabies remains high despite negative initial tests, a trial of empirical anti-scabietic treatment can be considered. If scabies has not been adequately ruled out, the necessity of long-term use of corticosteroids or immunosuppressants for suspected inflammatory skin conditions should be reassessed.\u003c/p\u003e \u003cp\u003eThis study was retrospective and conducted at a single center, with a relatively small number of hospitalized patients. Because the data were collected from medical records, some clinical details were incomplete. The limited number of severe misdiagnosis cases also meant that multivariable analysis was not feasible. In addition, misdiagnosis in scabies is influenced by clinical context and physician experience, which means it is difficult to conduct a prospective study. Further multicenter studies may help determine whether these findings are reproducible and applicable to broader patient populations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Medical Ethics Committee of the First Affiliated Hospital, Sun Yat-sen University (IIT-2026-196).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication was obtained from the participant (the patient) in this study. A detailed and through explanation has been given before receiving the consent to publish this case report including relevant information like pictures and clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used or analyzed in this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTW and LT contributed equally to this work. TW conceived the study and drafted the initial manuscript. LT contributed to data collection and manuscript drafting. LHZ participated in the data collection. JDH was responsible for project administration and supervision. NYL reviewed and edit the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTarbox M, Walker K, Tan M. Scabies. JAMA. 2018;320(6):612. \u003c/li\u003e\n\u003cli\u003eUygun A, Albayrak C, \u0026Ouml;zgen \u0026Uuml;, Kartal İ, Din\u0026ccedil;er OS, Kangal Şimşek H, et al. Scabies outbreak in paediatric malignancy patients: clinical and healthcare burden. J Hosp Infect. 2026;168:58-63. \u003c/li\u003e\n\u003cli\u003eThomas C, Coates SJ, Engelman D, Chosidow O, Chang AY. Ectoparasites: Scabies. J Am Acad Dermatol. 2020;82(3):533-548. \u003c/li\u003e\n\u003cli\u003eBetlloch-Mas I, Boluda-Verd\u0026uacute; E, Jara-Rico N, S\u0026aacute;nchez-Garc\u0026iacute;a V, Berbegal-De Gracia L, Chiner-Vives E. Scabies in Infants: Series of 51 Cases. Children. 2024;11(4):443. \u003c/li\u003e\n\u003cli\u003eEngelman D, Yoshizumi J, Hay RJ, Osti M, Micali G, Norton S, et al. The 2020 International Alliance for the Control of Scabies Consensus Criteria for the Diagnosis of Scabies. Br J Dermatol. 2020;183(5):808-820. \u003c/li\u003e\n\u003cli\u003eHengge UR, Currie BJ, J\u0026auml;ger G, Lupi O, Schwartz RA. Scabies: a ubiquitous neglected skin disease. Lancet Infect Dis. 2006;6(12):769-779. \u003c/li\u003e\n\u003cli\u003eMorrison EJ, Middleton J, Lanza S, Cowen JE, Hewitt K, Walker SL, et al. Do we know how scabies outbreaks in residential and nursing care homes for the elderly should be managed? A systematic review of interventions using a novel approach to assess evidence quality. Epidemiol Infect. 2019;147:e250.\u003c/li\u003e\n\u003cli\u003eZou Y, Hu W, Zheng J, Pan M. Nail infestation: an atypical presentation of typical scabies. Lancet. 2018;391(10136):2272. \u003c/li\u003e\n\u003cli\u003eLi LY, Sun H, Li XY, Liu JH, Liu WX, Luo DQ. Hemorrhagic bulla: a rare presentation of scabies. Ann Transl Med. 2019;7(5):107. \u003c/li\u003e\n\u003cli\u003eBhawan J, Milstone E, Malhotra R, Rosenfeld T, Appel M. Scabies presenting as bullous pemphigoid-like eruption. J Am Acad Dermatol. 1991;24(2 Pt 1):179-181. \u003c/li\u003e\n\u003cli\u003eWilson MM, Philpott CD, Breer WA. Atypical presentation of scabies among nursing home residents. J Gerontol A Biol Sci Med Sci. 2001;56(7):M424-M427. \u003c/li\u003e\n\u003cli\u003eLuo DQ, Huang MX, Liu JH, Tang W, Zhao YK, Sarkar R, Tang W, Huang MX. Bullous Scabies. Am J Trop Med Hyg. 2016;95(3):689-693. \u003c/li\u003e\n\u003cli\u003eRozenblat M, Halaj A, Levi A, Lapidoth M, Ziv M. Bullous Pemphigoid and Scabies: Is There an Association?. J Drugs Dermatol. 2022;21(9):1009-1011. \u003c/li\u003e\n\u003cli\u003eRan D, Bao F, Du D. Unique Scabies Presentation in a Patient with Bullous Pemphigoid. Am J Trop Med Hyg. 2024;111(3):455-456. \u003c/li\u003e\n\u003cli\u003eLima PB, Flor\u0026ecirc;ncio LC, Merlotto MR, Miot HA. Vesiculobullous scabies: an atypical manifestation in an adult. Int J Dermatol. 2020;59(11):e407-e408. \u003c/li\u003e\n\u003cli\u003eTalaga-Ćwiertnia K. Sarcoptes Infestation. What Is Already Known, and What Is New about Scabies at the Beginning of the Third Decade of the 21st Century? Pathogens. 2021;10(7):868. \u003c/li\u003e\n\u003cli\u003eHamm H, Stoevesandt J, Sunderk\u0026ouml;tter C. Skabies im Alter [Scabies in old age]. Z Gerontol Geriatr. 2019;52(8):795-807. \u003c/li\u003e\n\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"scabies, misdiagnosis, diagnostic error, interdigital, generalized eruption","lastPublishedDoi":"10.21203/rs.3.rs-9269090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9269090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSevere misdiagnosis of scabies can result in prolonged symptoms, inappropriate use of immunosuppressive therapy, secondary infections, and transmission within an institution. Hospitalized patients frequently present with atypical morphology or distribution, leading to uncertainty in diagnosis. Misdiagnosis of scabies among hospitalized patients remains poorly characterized.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study seeks to identify clinical characteristics associated with severe misdiagnosis of scabies, using a severity-based grading system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed a retrospective review of 41 patients admitted to the hospital and subsequently confirmed to have scabies. The severity of misdiagnosis was graded from level 0 to level 3, with levels 2 and 3 defined as severe misdiagnosis. Univariate logistic regression was performed to assess potential predictors of severe misdiagnosis, whereas univariate ordinal logistic regression (proportional odds model) was performed to assess potential predictors across the entire severity grading system (levels 0 to 3).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e10 severe scabies misdiagnoses (24.4%) were identified among the 41 patients. Severe misdiagnosis was protected against when interdigital involvement was present, with an OR of 0.048 (95% CI 0.008\u0026ndash;0.297; P\u0026thinsp;=\u0026thinsp;0.001). Severe misdiagnosis was more likely to occur if there was generalized involvement, with an OR of 7.27 (95% CI 1.31\u0026ndash;40.42; P\u0026thinsp;=\u0026thinsp;0.023). Ordinal regression analysis confirmed these findings: generalized involvement was associated with a significant increase in OR (14.74; P\u0026thinsp;=\u0026thinsp;0.002), while interdigital involvement was associated with a significant decrease in OR (0.106; P\u0026thinsp;=\u0026thinsp;0.003). There appeared to be a trend toward increased severity of misdiagnosis as age increased. Routine laboratory tests were poor predictors of severe misdiagnosis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn hospitalized patients with scabies, severe misdiagnosis is strongly associated with the absence of classical interdigital involvement and presence of generalized distribution. Although not statistically significant, blistering or bullous lesions may also mislead the diagnosis of scabies. Targeted examination of classic sites or empirical treatment when a diagnosis is suspected remains crucial, especially in cases of widespread or atypical presentations.\u003c/p\u003e","manuscriptTitle":"Clinical Characteristics Associated With Severe Misdiagnosis of Scabies: A Retrospective Hospital-Based Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 05:38:08","doi":"10.21203/rs.3.rs-9269090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"122722724411414366025417199923326401034","date":"2026-05-07T02:03:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288236117975494729136328460047649217861","date":"2026-05-05T07:53:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T19:11:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214828899281993773580784222021031989500","date":"2026-04-28T18:49:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46142350210882439703111958251954466722","date":"2026-04-28T14:23:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"108751250570050639633985507082859101078","date":"2026-04-28T10:53:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T10:11:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-03T10:17:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-02T13:28:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-02T13:27:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2026-03-30T15:13:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"78bc0b80-b585-41cd-ae88-19e9171fea27","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"122722724411414366025417199923326401034","date":"2026-05-07T02:03:59+00:00","index":65,"fulltext":""},{"type":"reviewerAgreed","content":"288236117975494729136328460047649217861","date":"2026-05-05T07:53:17+00:00","index":64,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T05:38:08+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 05:38:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9269090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9269090","identity":"rs-9269090","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}