**4. Eschar and lymphadenopathy**

This clinical syndrome has been recently reported in Europe, where it is named TIBOLA (TIck-BOrne LimphAdenopaty) or DEBONEL (*DErmacentor*-BOrne Necrosis-Erythema-Lymphadenopathy). *R. slovaca, R. rioja* and *R. raoultii* are the etiological agents, and *Dermacentor marginatus* is the main vector. This tick species is distributed all over Europe as well as in the North of Africa. Since this rickettsiosis appears in the coldest months of the year, the risk of acquisition for the travellers is lower than for the rickettsioses that are prevalent in spring and summer. In most cases (>90%) the tick-bite is located on the scalp (head) and always in the upper site of the body. After 1-15 days (mean: 4.8 days) of incubation period, the characteristic skin lesion starts as a crusted lesion at the site of the tick-bite (frequently on the scalp). A honey-like discharge from the lesion is observed in some cases. Few days later, a necrotic eschar appears (figure 12). This eschar is usually bigger than the one observed in MSF cases, and it is surrounded by an erythema. When the

Fig. 11. Map showing distribution of human cases of tick-borne rickettsioses and srub

This clinical syndrome has been recently reported in Europe, where it is named TIBOLA (TIck-BOrne LimphAdenopaty) or DEBONEL (*DErmacentor*-BOrne Necrosis-Erythema-Lymphadenopathy). *R. slovaca, R. rioja* and *R. raoultii* are the etiological agents, and *Dermacentor marginatus* is the main vector. This tick species is distributed all over Europe as well as in the North of Africa. Since this rickettsiosis appears in the coldest months of the year, the risk of acquisition for the travellers is lower than for the rickettsioses that are prevalent in spring and summer. In most cases (>90%) the tick-bite is located on the scalp (head) and always in the upper site of the body. After 1-15 days (mean: 4.8 days) of incubation period, the characteristic skin lesion starts as a crusted lesion at the site of the tick-bite (frequently on the scalp). A honey-like discharge from the lesion is observed in some cases. Few days later, a necrotic eschar appears (figure 12). This eschar is usually bigger than the one observed in MSF cases, and it is surrounded by an erythema. When the

typhus in Asia and Oceania.

**4. Eschar and lymphadenopathy** 

tick-bite is out of the head, the skin lesion resembles the erythema migrans of Lyme disease. Other typical manifestation, which is always present when the bite is on the head, is the presence of regional and very painful lymphadenopathies.

On the contrary of other rickettsioses, in DEBONEL/TIBOLA there are not systemic clinical signs (or they are rare), such as fever or maculo-papular rash (Oteo et al., 2004b). The clinical course is sub-acute and no severe complications have been described.

Fig. 12. DEBONEL/TIBOLA patient with the typical crusted lesion on the scalp.
