Disney rash mimicking cellulitis in two healthy young adults: A case report

Disney rash mimicking cellulitis in two healthy young adults: A case report | 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 Case Report Disney rash mimicking cellulitis in two healthy young adults: A case report Pathum Premaratna, Amanda Jayasinghe, Amarathunga D M, Ranjan Premaratna This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6408645/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Cellulitis is a common, potentially serious bacterial skin infection, warranting oral or intravenous antibiotics based on severity and immunity of the patient. Exercise induced vasculitis is commonly overlooked and results from prolonged standing and walking. It mimics cellulitis and management warrant rest, compression bandages and symptomatic treatment. Differentiating exercise induced vasculitis from cellulitis helps to curtail the use of unnecessary antibiotics. We present two young adults who developed exercise induced vasculitis and features that helped in differentiating it from cellulitis. Case presentation Two otherwise healthy young adults presented with painful erythematous lesions in lower limbs associated with pain, swelling, chills and sweats. They had been standing for long hours. Although cellulitis was considered as the most likely initial diagnosis, detection of lesions in both lower limbs, normal laboratory parameters, evidence of similar illness among few other healthy adults made exercise induced vasculitis more likely. Both responded well to keeping limbs elevated, compression bandages and pain relief. Conclusion Exercise induced vasculitis should be considered in patients who develop painful tender lesions in lower limbs mimicking cellulitis especially have engaged in activities involving prolonged standing, because this illness can be managed with simple measures and does not warrant antibiotics. Exercise induced vasculitis Cellulitis Disney rash Figures Figure 1 Figure 2 Figure 3 Background Cellulitis is a superficial infection of the skin caused commonly by streptococcal or staphylococcal organisms entering through abraded skin. If severe and left untreated, it can cause lymphadenitis, lymphangitis or septicemia and may rapidly become life-threatening [ 1 ]. Cellulitis commonly affects the lower legs, however, can involve anywhere in the body. Based on the severity and underlying immune status of the patient, treatment is tailored to variable period of either oral or intravenous antibiotics. Exercise-induced vasculitis, Disney rash, Hikers or golfer's vasculitis, jogger’s petechiae, sport-induced vasculitis, and marathon runner’s vasculitis all describe the same illness where prolonged standing and walking/ running in hot climates results in a discrete red itchy or painful rash in lower limbs due to neutrophilic inflammatory disorder involving the small or medium-sized blood vessels of the skin and subcutaneous tissue [ 2 , 3 , 4 ]. Areas of compression, such as under the sock, are usually spared. Management includes short period bed rest with elevation of limbs, compression bandages, analgesics for pain, hydration and avoidance of tight garments [ 4 ]. Differentiating exercise induced vasculitis from cellulitis helps to curtail the use of unnecessary antibiotics. We present two young adults who developed exercise induced vasculitis and features that helped in differentiating it from cellulitis. Case presentations Two young adults, the first, a 27-year-old male intern medical officer during the first week of medical clerkship and the second, a 26-year-old female medical student during the final week of clinical appointment in Gynecology & Obstetrics, presented with an acute onset painful skin lesions prominently on the right leg. The first experienced acute pain, swelling and night chills on day one of illness and the second, in addition to above features had mild itching before the occurrence of the rash. Both noticed the rash, prominent swelling and pain towards the end of the day and found it difficult to work standing. The first, had a sea bath four days before the rash, however, denied any pain or contact with sea urchins or trauma while in the sea. Neither experienced prior wound, stings or bites. However, the first claimed a similar rash occurring in a few other intern medical officers working elsewhere and were treated as cellulitis. In both, the rash was erythematous with raising towards the middle and pale tender points in the center (Fig. 1,2,3). Separate lesions of varying sizes (Fig. 2) were noted around the main lesion and, similar patchy involvement to a minor degree was noted in the other lower limb in both patients. The distal area showed tender pitting oedema. There were no scratch marks, eschars, entry points or any abrasions, associated lymphangitis or lymphadenitis. Both had no previous similar encounters. Pending investigation results, the first was treated with an intense course of antibiotics (one day of intra venous flucloxacillin and clindamycin) considering it to be “cellulitis” and, as he wanted to go back to work at the earliest. However, the initial investigations did not support cellulitis (No neutrophilic leukocytosis, normal CRP (< 6mg/dL) and mildly raised ESR (27 mm 1st hr), normal UFR and ASOT < 200. Furthermore, involvement of both limbs, the history of similar involvement in few other young doctors immediately after commencing internship elsewhere, prolonged standing and walking for nearly 20 hours a day during busy work schedule, the possibility of exercise induced vasculitis was considered as the most likely diagnosis. Therefore, antibiotics were discontinued, and he was treated with rest and compression bandages. He was discharged within 24 hours. He gradually became better over the next 3–4 days and the rash and discoloration disappeared within the next 2–3 weeks. This experience helped in the early diagnosis of the second patient who presented about 5 weeks after the first, who was in the latter part of a professorial appointment and had kept standing in the busy labor room for more than 12–16 hours. She was immediately commenced on adequate rest and compression bandages. Oral clarithromycin was added pending investigation results however, they were stopped within 24 hours. She made a rapid recovery and attended to her work within 48 hours with advice on using compression bandages, intermittent rest, wearing non-tight garments, and taking adequate fluids. Both had rapid recoveries. A tissue diagnosis was not performed as both did not consent for superficial skin biopsies and said they wanted to return to work at the earliest. Discussion Both these healthy young adults presented with erythematous skin lesions in their legs with distal swelling. It happened very rapidly and the first was in severe pain and the second with heavy limbs. Both had chills and sweats, mild fever was detected only in the first. The first had no itching, however both had bilateral involvement with varying severity. In both the lesions were well demarcated, with no raised edges. However, within these lesions there were palpable pale tender areas (Fig. 3). Based on the bilateral nature of illness, absent neutrophil leukocytosis, normal CRP, the history of “cellulitis” among some colleagues elsewhere during the early internship period, (although they had received treatment for “cellulitis”) pointed towards the possibility of exercise induced vasculitis rather than cellulitis and appropriate management was instituted with rapid improvement. Although the first patient received antibiotics, they were discontinued within 48 hours. The experience with the first patient within 6 weeks helped in the early diagnosis and management of the second patient. We highlight the importance of considering exercise induced vasculitis for similar clinical presentations among otherwise healthy adults who engage in busy activities with prolonged standing to prevent use of appropriate management without exposing them for various combinations of antibiotics. Declarations Ethics approval and consent to participate: Not relevant to this article as the two patients being the first two authors who were very keen to publish their experience so that they could help other similar patients who would run the risk of receiving inappropriate courses of antibiotics for similar illnesses. Further, they have given written informed consent to publish their clinical details and the relevant photos. Clinical Trial: Not relevant Consent for publication The two indexed patients are the first and second authors in the manuscript and both are in the medical profession. They were very keen to publish their clinical presentations as they were the opinion that knowledge of this illness would help other similar patients to be managed without using unnecessary courses of antibiotics. They also have given written consent to publish clinical details and relevant photos. Availability of data and materials Not applicable: No datasets were generated or analysed during the current study Competing interests None declared Funding None Author contributions PTP: Providing and gathering clinical and relevant laboratory results, and writing up the manuscript, AGJ: Providing and gathering clinical and relevant laboratory results, and writing up the manuscript. DMA: confirming the diagnosis, management decisions, and writing up the manuscript. RP: Management of the two cases, writing up the manuscript. Acknowledgements: None References Cranendonk DR, Lavrijsen APM, Prins JM, Wiersinga WJ. Cellulitis: current insights into pathophysiology and clinical management. Neth J Med. 2017;759:366–78. Carlson JA, Chen KR. Cutaneous vasculitis update: small vessel neutrophilic vasculitis syndromes. Am J Dermatopathol. 2006;28:486–506. 10.1097/01.dad.0000246646.45651.a2 . Ramelet AA. Exercise-induced vasculitis. J Eur Acad Dermatol Venereol. 2006;20:423–7. 10.1111/j.1468-3083.2006.01504.x . Espitia O, Dréno B, Cassagnau E, et al. Exercise-induced vasculitis: a review with illustrated cases. Am J Clin Dermatol. 2016;17:635–42. Additional Declarations No competing interests reported. Supplementary Files CAREchecklistEnglish2013.pdf Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6408645","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":454627728,"identity":"f078b648-e4db-4030-88e2-33fe644292e1","order_by":0,"name":"Pathum Premaratna","email":"","orcid":"","institution":"Base Hospital Tangalle Sri Lanka","correspondingAuthor":false,"prefix":"","firstName":"Pathum","middleName":"","lastName":"Premaratna","suffix":""},{"id":454627729,"identity":"4f5b44e6-6afc-4d68-b5cf-8019d5449572","order_by":1,"name":"Amanda Jayasinghe","email":"","orcid":"","institution":"University of 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commonly by streptococcal or staphylococcal organisms entering through abraded skin. If severe and left untreated, it can cause lymphadenitis, lymphangitis or septicemia and may rapidly become life-threatening [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Cellulitis commonly affects the lower legs, however, can involve anywhere in the body. Based on the severity and underlying immune status of the patient, treatment is tailored to variable period of either oral or intravenous antibiotics.\u003c/p\u003e \u003cp\u003eExercise-induced vasculitis, Disney rash, Hikers or golfer's vasculitis, jogger\u0026rsquo;s petechiae, sport-induced vasculitis, and marathon runner\u0026rsquo;s vasculitis all describe the same illness where prolonged standing and walking/ running in hot climates results in a discrete red itchy or painful rash in lower limbs due to neutrophilic inflammatory disorder involving the small or medium-sized blood vessels of the skin and subcutaneous tissue [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Areas of compression, such as under the sock, are usually spared. Management includes short period bed rest with elevation of limbs, compression bandages, analgesics for pain, hydration and avoidance of tight garments [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDifferentiating exercise induced vasculitis from cellulitis helps to curtail the use of unnecessary antibiotics. We present two young adults who developed exercise induced vasculitis and features that helped in differentiating it from cellulitis.\u003c/p\u003e"},{"header":"Case presentations","content":"\u003cp\u003eTwo young adults, the first, a 27-year-old male intern medical officer during the first week of medical clerkship and the second, a 26-year-old female medical student during the final week of clinical appointment in Gynecology \u0026amp; Obstetrics, presented with an acute onset painful skin lesions prominently on the right leg. The first experienced acute pain, swelling and night chills on day one of illness and the second, in addition to above features had mild itching before the occurrence of the rash. Both noticed the rash, prominent swelling and pain towards the end of the day and found it difficult to work standing. The first, had a sea bath four days before the rash, however, denied any pain or contact with sea urchins or trauma while in the sea. Neither experienced prior wound, stings or bites. However, the first claimed a similar rash occurring in a few other intern medical officers working elsewhere and were treated as cellulitis.\u003c/p\u003e \u003cp\u003eIn both, the rash was erythematous with raising towards the middle and pale tender points in the center (Fig.\u0026nbsp;1,2,3). Separate lesions of varying sizes (Fig.\u0026nbsp;2) were noted around the main lesion and, similar patchy involvement to a minor degree was noted in the other lower limb in both patients. The distal area showed tender pitting oedema. There were no scratch marks, eschars, entry points or any abrasions, associated lymphangitis or lymphadenitis. Both had no previous similar encounters. Pending investigation results, the first was treated with an intense course of antibiotics (one day of intra venous flucloxacillin and clindamycin) considering it to be \u0026ldquo;cellulitis\u0026rdquo; and, as he wanted to go back to work at the earliest. However, the initial investigations did not support cellulitis (No neutrophilic leukocytosis, normal CRP (\u0026lt;\u0026thinsp;6mg/dL) and mildly raised ESR (27 mm 1st hr), normal UFR and ASOT\u0026thinsp;\u0026lt;\u0026thinsp;200. Furthermore, involvement of both limbs, the history of similar involvement in few other young doctors immediately after commencing internship elsewhere, prolonged standing and walking for nearly 20 hours a day during busy work schedule, the possibility of exercise induced vasculitis was considered as the most likely diagnosis. Therefore, antibiotics were discontinued, and he was treated with rest and compression bandages. He was discharged within 24 hours. He gradually became better over the next 3\u0026ndash;4 days and the rash and discoloration disappeared within the next 2\u0026ndash;3 weeks. This experience helped in the early diagnosis of the second patient who presented about 5 weeks after the first, who was in the latter part of a professorial appointment and had kept standing in the busy labor room for more than 12\u0026ndash;16 hours. She was immediately commenced on adequate rest and compression bandages. Oral clarithromycin was added pending investigation results however, they were stopped within 24 hours. She made a rapid recovery and attended to her work within 48 hours with advice on using compression bandages, intermittent rest, wearing non-tight garments, and taking adequate fluids. Both had rapid recoveries. A tissue diagnosis was not performed as both did not consent for superficial skin biopsies and said they wanted to return to work at the earliest.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBoth these healthy young adults presented with erythematous skin lesions in their legs with distal swelling. It happened very rapidly and the first was in severe pain and the second with heavy limbs. Both had chills and sweats, mild fever was detected only in the first. The first had no itching, however both had bilateral involvement with varying severity. In both the lesions were well demarcated, with no raised edges. However, within these lesions there were palpable pale tender areas (Fig.\u0026nbsp;3). Based on the bilateral nature of illness, absent neutrophil leukocytosis, normal CRP, the history of \u0026ldquo;cellulitis\u0026rdquo; among some colleagues elsewhere during the early internship period, (although they had received treatment for \u0026ldquo;cellulitis\u0026rdquo;) pointed towards the possibility of exercise induced vasculitis rather than cellulitis and appropriate management was instituted with rapid improvement. Although the first patient received antibiotics, they were discontinued within 48 hours. The experience with the first patient within 6 weeks helped in the early diagnosis and management of the second patient.\u003c/p\u003e \u003cp\u003eWe highlight the importance of considering exercise induced vasculitis for similar clinical presentations among otherwise healthy adults who engage in busy activities with prolonged standing to prevent use of appropriate management without exposing them for various combinations of antibiotics.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot relevant to this article as the two patients being the first two authors who were very keen to publish their experience so that they could help other similar patients who would run the risk of receiving inappropriate courses of antibiotics for similar illnesses. Further, they have given written informed consent to publish their clinical details and the relevant photos.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot relevant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two indexed patients are the first and second authors in the manuscript and both are in the medical profession. They were very keen to publish their clinical presentations as they were the opinion that knowledge of this illness would help other similar patients to be managed without using unnecessary courses of antibiotics. They also have given written consent to publish clinical details and relevant photos.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable: No datasets were generated or analysed during the current study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePTP:\u003c/strong\u003e Providing and gathering clinical and relevant laboratory results, and writing up the manuscript,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAGJ:\u003c/strong\u003e Providing and gathering clinical and relevant laboratory results, and writing up the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDMA:\u003c/strong\u003e confirming the diagnosis, management decisions, and writing up the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRP:\u003c/strong\u003e Management of the two cases, writing up the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCranendonk DR, Lavrijsen APM, Prins JM, Wiersinga WJ. Cellulitis: current insights into pathophysiology and clinical management. Neth J Med. 2017;759:366\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarlson JA, Chen KR. Cutaneous vasculitis update: small vessel neutrophilic vasculitis syndromes. Am J Dermatopathol. 2006;28:486\u0026ndash;506. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.dad.0000246646.45651.a2\u003c/span\u003e\u003cspan address=\"10.1097/01.dad.0000246646.45651.a2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamelet AA. Exercise-induced vasculitis. J Eur Acad Dermatol Venereol. 2006;20:423\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1468-3083.2006.01504.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1468-3083.2006.01504.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEspitia O, Dr\u0026eacute;no B, Cassagnau E, et al. Exercise-induced vasculitis: a review with illustrated cases. Am J Clin Dermatol. 2016;17:635\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Exercise induced vasculitis, Cellulitis, Disney rash","lastPublishedDoi":"10.21203/rs.3.rs-6408645/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6408645/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCellulitis is a common, potentially serious bacterial skin infection, warranting oral or intravenous antibiotics based on severity and immunity of the patient. Exercise induced vasculitis is commonly overlooked and results from prolonged standing and walking. It mimics cellulitis and management warrant rest, compression bandages and symptomatic treatment. Differentiating exercise induced vasculitis from cellulitis helps to curtail the use of unnecessary antibiotics. We present two young adults who developed exercise induced vasculitis and features that helped in differentiating it from cellulitis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase presentation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTwo otherwise healthy young adults presented with painful erythematous lesions in lower limbs associated with pain, swelling, chills and sweats. They had been standing for long hours. Although cellulitis was considered as the most likely initial diagnosis, detection of lesions in both lower limbs, normal laboratory parameters, evidence of similar illness among few other healthy adults made exercise induced vasculitis more likely. Both responded well to keeping limbs elevated, compression bandages and pain relief.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eExercise induced vasculitis should be considered in patients who develop painful tender lesions in lower limbs mimicking cellulitis especially have engaged in activities involving prolonged standing, because this illness can be managed with simple measures and does not warrant antibiotics.\u003c/p\u003e","manuscriptTitle":"Disney rash mimicking cellulitis in two healthy young adults: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-15 10:30:45","doi":"10.21203/rs.3.rs-6408645/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"919cfbd0-d3f3-444b-a92e-4ff91d1cfa23","owner":[],"postedDate":"May 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-30T06:53:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-15 10:30:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6408645","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6408645","identity":"rs-6408645","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}