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Boutonneuse Fever Clinical Presentation

  • Author: Jason F Okulicz, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD  more...
Updated: Mar 11, 2016


The incubation period for boutonneuse fever (BF), also known as Mediterranean spotted fever (MSF), is approximately 5-7 days after the infecting tick bite, which is typically painless and often goes unnoticed. About 37% of patients give a history of a tick bite; about 89% report having had contact with a dog; and some give a history of travel to an endemic area.

Because there is no test that can reliably confirm BF in its early stages, the diagnosis is commonly made on the basis of clinical findings.[17] The clinical diagnosis is obvious when a history of travel to an endemic area is coupled with the following triad:

  • Fever
  • Rash (exanthem)
  • Tache noire

More specifically, patients commonly report the following:

  • Fever of 39-41°C
  • Nonpruritic skin rash, mainly on the lower legs, occurring 2-6 days after the fever appeared
  • Myalgia, arthralgia, or both

BF cases are on the increase all over the world and should be considered in all febrile patients returning from abroad, especially from endemic areas (eg, the Mediterranean basin). About 88% of BF cases are diagnosed between June and September (as a reflection of the reproduction cycle of Rhipicephalus); however, physicians should be aware that climate changes are leading to increases in the number of off-season BF cases. Spotless fever and cases appearing in the winter also may be due to Rickettsia infection; suspicion is required.


Physical Examination

Findings that may be observed in a patient with BF include the following:

  • High fever
  • Maculopapular rash
  • Tache noire (eschar)
  • Stupor
  • Pneumonia
  • Bradycardia
  • Coma
  • Jaundice
  • Gastrointestinal (GI) bleeding
  • Arthralgic and myalgic arthritis
  • Hepatomegaly and splenomegaly
  • Orchitis
  • Conjunctival hyperemia
  • Meningism [18]
  • Meningitis
  • Local lymphadenopathy
  • Retinopathy, [19] sensorineural hearing loss, [20] and other neurologic manifestations (rare)

The presence of malignant BF is indicated when 2 or more specific clinical symptoms occur in conjunction with 2 or more specific laboratory test results (see DDx).



Complications of BF tend to occur mainly in patients who are immunocompromised or elderly and who present with the malignant form of the disease. In Spain, complications are observed in about 22% of BF cases. Generally, however, the complication rate is estimated to be in the range of 1-20%.

The following complications have been reported[21] :

  • Renal failure - This is mainly due to renal vasculitis, acute tubular necrosis, or perivascular interstitial glomerulonephritis
  • Respiratory failure
  • GI bleeding
  • Stroke
  • Deep venous thrombosis (DVT) - This is observed in about 9% of patients during the late acute phase and the early convalescent phase of BF
  • Arthromyalgia (16-76% of patients) and arthritis (rare)
  • Pulmonary complications (very rare)
  • Meningoencephalitic involvement - This may occur during the acute phase (lymphocytic coma or meningitis)
  • Myelitis - This tends to occur early in the convalescent phase as acute-onset paraplegia involving the lumbosacral spinal cord (very rare)
  • Septic shock
  • Multiorgan failure
  • Hepatosplenomegaly
  • Autoimmune anemia
Contributor Information and Disclosures

Jason F Okulicz, MD, FACP, FIDSA Director, HIV Medical Evaluation Unit, Infectious Disease Service, San Antonio Military Medical Center; Associate Professor of Medicine, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences; Clinical Associate Professor of Medicine, University of Texas Health Science Center at San Antonio; Adjunct Clinical Instructor, Feik School of Pharmacy, University of the Incarnate Word

Jason F Okulicz, MD, FACP, FIDSA is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America

Disclosure: Nothing to disclose.


Pierre A Dorsainvil, MD Medical Director, HIV Specialist, Palm Beach County Main Detention Center; Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Lake Ida Medical Center

Disclosure: Nothing to disclose.

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Mark S Rasnake, MD, FACP Assistant Professor of Medicine, Program Director, Internal Medicine Residency, University of Tennessee Graduate School of Medicine; Consulting Staff, Department of Infectious Diseases, University of Tennessee Medical Center at Knoxville

Mark S Rasnake, MD, FACP is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.


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.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Paul Krusinski, MD Director of Dermatology, Fletcher Allen Health Care; Professor, Department of Internal Medicine, University of Vermont College of Medicine

Paul Krusinski, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Joseph Richard Masci, MD Professor of Medicine, Professor of Preventive Medicine, Mount Sinai School of Medicine; Director of Medicine, Elmhurst Hospital Center

Joseph Richard Masci, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Association of Professors of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, University of Medicine and Dentistry of New Jersey-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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robin Travers, MD Assistant Professor of Medicine (Dermatology), Dartmouth University School of Medicine; Staff Dermatologist, New England Baptist Hospital; Private Practice, SkinCare Physicians

Robin Travers, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Informatics Association, Massachusetts Medical Society, Medical Dermatology Society, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Anna Zalewska, MD, PhD Professor of Dermatology and Venereology, Psychodermatology Department, Chair of Clinical Immunology and Microbiology, Medical University of Lodz, Poland

Disclosure: Nothing to disclose.

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