eMedicine Specialties > Dermatology > Bacterial Infections

Rocky Mountain Spotted Fever: Follow-up

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

Follow-up

Further Inpatient Care

  • All Rocky Mountain spotted fever (RMSF) patients with unstable vital signs, neurologic symptoms, elevated creatinine, or vomiting should be hospitalized for administration of intravenous therapy and supportive care.

Further Outpatient Care

  • Patients who are in the early phases of Rocky Mountain spotted fever (RMSF) or who have only mild illness may be treated on an outpatient basis with oral antibiotics.

Inpatient & Outpatient Medications

Deterrence/Prevention

  • Patients can reduce the risk of tick bites by adhering to the following guidelines:
    • Avoid a tick's natural habitat (wooded areas).
    • Wear light-colored, long-sleeved clothing.
    • Tuck pants into socks, and tape the exposed edges.
    • Promptly remove and decontaminate clothing after tick exposure.
    • Use the tick repellent, diethyltoluamide (DEET), on bare skin.
    • Use Permethrin on the clothes as acaricide.
    • Perform frequent tick checks so they can be removed before prolonged attachment.
  • Environmental approaches to reduce vectors and hosts include the following:
    • Keep lawns and brush properly maintained.
    • Remove animal nests and unnecessary vegetation.
    • Avoid leaving trash around the outside of the home.
    • Check family pets daily for tick exposure.
  • In the future, vaccinations may become the best means to rid endemic areas of RMSF. Recombinant DNA and recombinant Mycobacterium vaccae vaccines exploit the immunity-conferring rickettsial outer membrane to stimulate protective immunity.13

Complications

  • Mild hemodynamic complications are common and include thrombocytopenia (<150 X 109/L) in 32-52% of patients.
  • Disseminated intravascular coagulation occurs in 9% of cases.
  • Capillary leakage may result in hypoalbuminemia and contribute to severe hypotension.
  • Gangrene can result from small vessel occlusion. If systemic medications cannot reach the distal extremities due to ischemia, amputation may be necessary leading to permanent disfigurement for the patient.
  • Cases of acute disseminated encephalomyelitis and meningoencephalitis have been reported.
  • The presence of acute renal failure, which has been associated with severe RMSF, is strongly associated with a worse prognosis, including death.
  • An acute, aseptic monarticular arthritis that resolves with treatment of the systemic illness has occurred in association with RMSF.
  • Obtundation and coma requiring mechanical ventilation may occur.
  • Central nervous system abnormalities, such as ataxia, hyperreflexia, and global decrement in cognitive capability, have persisted, in some instances, for up to a month and beyond after resolution of RMSF. Paraparesis; hearing loss; peripheral neuropathy; language disorders; and cerebellar, vestibular, and motor dysfunction are all potential long-term neurologic sequelae.
  • Others complications include interstitial pneumonia, myocarditis, and bowel and bladder incontinence.

Prognosis

  • Most patients recover without sequelae; however, morbidity during the illness may be severe.
  • As stated in Morbidity/Mortality, fatalities are more likely to occur if a delay in diagnosis and treatment occurs. In addition, factors associated with increased risk of death include patient age older than 40 years, severe disease, lack of classic symptoms, and absence of a tick bite.

Patient Education

  • Advise patients that historical methods of tick removal, such as heat from matches, turpentine, kerosene, petroleum jelly, glycerin, nail polish remover, and rubbing alcohol should not be used in attempt to remove an imbedded tick. Gentle traction with curved forceps or fine point tweezers, as close to the skin as possible, should be used to slowly and steadily pull the tick straight outward from its site of attachment. The body of the tick should not be manipulated in any way as fluid containing infectious organisms may be expressed. The tick should be saved in a plastic bag for future identification. A thorough cleansing of the site with soap and water should follow removal.
  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Ticks.

Miscellaneous

Medicolegal Pitfalls

  • Failure to elicit an appropriate detailed history
  • Dismissing RMSF as a diagnosis when no history of a tick bite exists
  • Rejecting RMSF as a diagnosis when no rash is present
  • Waiting for laboratory results before initiating treatment
  • Excluding RMSF as a diagnosis based on geography
  • Not including RMSF as a diagnosis based on season
  • Failing to treat all nonpregnant patients, including children, with doxycycline

Special Concerns

  • A diagnosis of RMSF was made in a patient after testing was performed because of the patient's dog being afflicted by the disease.
 


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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