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Rocky Mountain Spotted Fever: Differential Diagnoses & Workup

Author: Nicole L Lacz, MD, Chief Resident, Department of Radiology, St Barnabas Medical Center
Coauthor(s): Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, New Jersey Medical School
Contributor Information and Disclosures

Updated: Jun 26, 2009

Differential Diagnoses

Dengue
Lyme Disease
Measles, Rubeola

Other Problems to Be Considered

Meningococcal infections
Coxsackievirus A9
Drug reactions6
Echovirus 9
Epstein-Barr virus
Cytomegalovirus
Disseminated gonococcal infections
Staphylococcus aureus septicemia
Idiopathic thrombocytopenia purpura
Thrombotic thrombocytopenic purpura
Acute abdomen
Appendicitis7
Acute cholecystitis8
Other tick borne illnesses, such as Lyme disease; Q fever; and especially, ehrlichiosis9

Workup

Laboratory Studies

  • CBC count with differential for Rocky Mountain spotted fever (RMSF)
    • The white blood count may be depressed, normal, or elevated.
    • Thrombocytopenia is usually evident.
    • The patient may be anemic.
  • Chemistry panel
    • Hyponatremia is sometimes present.
    • An elevated blood urea nitrogen level may indicate azotemia.
  • Liver function tests: Elevated serum transaminase levels are present in most patients.
  • Weil-Felix assay: This assay is no longer used because of its poor sensitivity and specificity.
  • Indirect fluorescent antibody
    • Indirect fluorescent antibody (IFA) test is the best and most widely used serologic test. It has a high specificity and sensitivity (94%), thus making it the reference standard and test currently used by the CDC.
    • Antibodies do not usually appear until 7-14 days after infection. A 4-fold rise of titers to greater than or equal to 1:64 of two sequential samples is diagnostic. A single sample should not be considered valid since antibodies can be detected for years after initial exposure.
    • Routine IFA detects both immunoglobulin M and immunoglobulin G antibodies but cannot distinguish between infection with R rickettsii and other spotted fever pathogens, such as Rickettsia akari and Rickettsia conorii. Immunofluorescence using species-specific monoclonal antibodies is specific for R rickettsii, but it is not widely available.
  • Direct immunofluorescence/immunostaining: This test can be used in the acute setting, with a sensitivity of 70%, to directly visualize organisms within a skin biopsy specimen.
  • Immunoperoxidase staining of paraffin-embedded biopsy tissue
    • This staining can be examined by bright-field microscopy.
    • Its sensitivity and specificity is identical to IFA.
    • Immunoperoxidase staining has easier antigen localization and viewing of histopathology, but it is not as quick as IFA.
  • Polymerase chain reaction techniques: This method may provide a more timely diagnosis, but it is not sensitive until late in the clinical course.
  • Light microscopy: Giemsa and Gimenez stains can be used to visualize R rickettsii.
  • Electron microscopy: A round/oval electron-dense organism surrounded by an electron-lucent halo may be seen.

Imaging Studies

  • Although not common, abnormal findings on neuroimaging studies do occur in Rocky Mountain spotted fever (RMSF). These findings include infarctions, prominent perivascular spaces, meningeal enhancement, and cerebral edema.
  • In Rocky Mountain spotted fever (RMSF), abnormal findings on CT scans or MRIs are associated with unfavorable clinical outcomes; however, such imaging techniques do not alter the patient's treatment.

Other Tests

  • Electrocardiographic abnormalities ranging from atrial fibrillation to nonspecific ST-wave changes have been reported.
  • EEG should be performed if neurologic manifestations, such as generalized hyperreflexia and impaired mental status, persist.

Procedures

  • A lumbar puncture may be performed. A lymphocytic cerebrospinal fluid pleocytosis may be found.

Histologic Findings

In Rocky Mountain spotted fever (RMSF), examination of a biopsy specimen usually reveals a lymphohistiocytic vasculitis in the mid dermis and the reticular dermis with predominantly perivascular extravasation of erythrocytes, as well as edema. This may progress to a leukocytoclastic vasculitis with vacuolar degeneration in the basal layer. Apoptotic keratinocytes and acute neutrophilic eccrine hidradenitis may also be seen. Extravasation of erythrocytes is present, and, often times, focal, occluding fibrin thrombi are present in the small vessels, which may lead to microinfarcts and capillary wall necrosis. The 0.3 X 1 µm organism can be identified by using immunocytochemistry of the skin lesions or Giemsa and Gimenez stains with light microscopy. R rickettsii may be found in the cytoplasm and nuclei of endothelial cells.

More on Rocky Mountain Spotted Fever

Overview: Rocky Mountain Spotted Fever
Differential Diagnoses & Workup: Rocky Mountain Spotted Fever
Treatment & Medication: Rocky Mountain Spotted Fever
Follow-up: Rocky Mountain Spotted Fever
Multimedia: Rocky Mountain Spotted Fever
References
Further Reading
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Keywords

Rocky Mountain spotted fever, RMSF, Rickettsia rickettsii, R rickettsii, tick-borne diseases, rickettsioses, Amblyomma cajennense, A cajennense, Rhipicephalus sanguineous, R sanguineous, Dermacentor andersoni, D andersoni, tick fever, spotted fever

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Contributor Information and Disclosures

Author

Nicole L Lacz, MD, Chief Resident, Department of Radiology, St Barnabas Medical Center
Nicole L Lacz, MD is a member of the following medical societies: Alpha Omega Alpha, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Rajendra Kapila, MD, MBBS, Professor of Medicine, Department of Medicine, UMDNJ, New Jersey Medical School
Rajendra Kapila, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Infectious Diseases Society of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Noah S Scheinfeld, MD, JD, FAAD, Assistant Clinical Professor, Department of Dermatology, Columbia University; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Private Practice
Noah S Scheinfeld, MD, JD, FAAD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Optigenex Consulting fee Independent contractor

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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