eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Mediterranean Spotted Fever

Author: Jason F Okulicz, MD, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff, Infectious Disease Service, Brooke Army Medical Center
Coauthor(s): Mark S Rasnake, MD, 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; 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; 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
Contributor Information and Disclosures

Updated: Sep 18, 2008

Introduction

Background

Mediterranean spotted fever, also known as boutonneuse fever, is transmitted by the dog tick Rhipicephalus sanguineus. The tick bite causes a characteristic rash and a distinct mark, ie, a tache noire (black spot) at the site of the bite.

The etiologic agent that causes Mediterranean spotted fever is Rickettsia conorii, which is also associated with Marseilles fever, Kenya tick typhus, South African tick bite fever, Indian tick typhus, and Israeli tick typhus. Persons with Israeli spotted fever seldom, if ever, develop the tache noire at the site of the tick bite.

Rickettsiae are obligate, intracellular gram-negative coccobacilli that measure 1 µm X 0.3 µm and are found within the cytoplasm and occasionally the nucleus of eukaryotic cells.

Mediterranean spotted fever and African tick bite fever are separate illnesses in the same geographic area. In contrast to Mediterranean spotted fever, African tick bite fever causes local adenopathy and multiple eschars.

The frequency of travel-associated Mediterranean spotted fever has increased worldwide because of increased travel to endemic areas, including ecotourism.

Life-threatening complications or permanent disabilities may result from a delayed diagnosis of Mediterranean spotted fever and the common practice of prescribing beta-lactam antibiotics as empiric therapy.

Pathophysiology

The pathophysiologic hallmark of R conorii infection is the invasion of vascular endothelial cells by the organism, causing endothelial injury and tissue necrosis, which is illustrated by the tache noire or eschar at the tick bite site. Thrombosis is not an important pathogenic mechanism in this infection, but deep venous thrombosis can occur late in the course of illness.

Frequency

United States

Mediterranean spotted fever is uncommon in the United States. A similar disease, Rocky Mountain spotted fever, is found in the United States. Rocky Mountain spotted fever is caused by Rickettsia rickettsii, for which the ixodid tick is the vector.

International

Mediterranean spotted fever, caused by R conorii, is prevalent in southern Europe, Africa, and central Asia, including India.

Mortality/Morbidity

Until recently, Mediterranean spotted fever was characterized as a benign rickettsiosis; however, Guillain-Barré syndrome,1 polyneuropathy,1 altered mental status, hepatomegaly, acute renal failure, thrombocytopenia, hypoxemia, and death have been reported. Factors associated with more severe disease include older age, alcoholism, and glucose-6-phosphatase dehydrogenase (G-6-PD) deficiency. Mediterranean spotted fever carries an overall mortality rate of approximately 2%.

Clinical

History

  • The incubation period of Mediterranean spotted fever is approximately 5-7 days after an often-unnoticed, painless tick bite.
  • History typically includes physical contact with dogs in endemic areas.
  • Suspect Mediterranean spotted fever in any patient who presents with fever, history of tick bite, rash, and/or eschar (tache noire).

Physical

  • Patients with Mediterranean spotted fever usually present with the following:
    • High fever
    • Maculopapular rash
    • Eschar
    • Headache
    • Myalgias and arthralgias
    • Malaise
    • Nausea and/or vomiting
    • Diarrhea
    • Retinopathy,2 sensorineural hearing loss,3 and other neurologic manifestations (although rare)

Causes

  • R conorii transmitted by the dog tick, R sanguineus, causes Mediterranean spotted fever.

More on Mediterranean Spotted Fever

Overview: Mediterranean Spotted Fever
Differential Diagnoses & Workup: Mediterranean Spotted Fever
Treatment & Medication: Mediterranean Spotted Fever
Follow-up: Mediterranean Spotted Fever
References
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References

  1. Popivanova N, Hristova D, Hadjipetrova E. Guillain-Barré polyneuropathy associated with mediterranean spotted fever: case report. Clin Infect Dis. Dec 1998;27(6):1549. [Medline].

  2. Leone S, De Marco M, Ghirga P, et al. Retinopathy in Rickettsia conorii Infection: Case Report in an Immunocompetent Host. Infection. Aug 2008;36(4):384-6. [Medline].

  3. Tsiachris D, Deutsch M, Vassilopoulos D, et al. Sensorineural hearing loss complicating severe rickettsial diseases: report of two cases. J Infect. Jan 2008;56(1):74-6. [Medline].

  4. Aharonowitz G, Koton S, Segal S, et al. Epidemiological characteristics of spotted fever in Israel over 26 years. Clin Infect Dis. Nov 1999;29(5):1321-2. [Medline].

  5. Anton E, Font B, Munoz T, et al. Clinical and laboratory characteristics of 144 patients with mediterranean spotted fever. Eur J Clin Microbiol Infect Dis. Feb 2003;22(2):126-8. [Medline].

  6. Burgert SJ. Clinical manifestations of African tick-bite fever in the returning traveler. Infect Dis Clin Pract. 2000;9:137-8.

  7. Cascio A, Colomba C, Antinori S, et al. Clarithromycin versus azithromycin in the treatment of Mediterranean spotted fever in children: a randomized controlled trial. Clin Infect Dis. Jan 15 2002;34(2):154-8. [Medline].

  8. Elghetany MT, Walker DH. Hemostatic changes in Rocky Mountain spotted fever and Mediterranean spotted fever. Am J Clin Pathol. Aug 1999;112(2):159-68. [Medline].

  9. Jenkins DR, Rees JC, Pollitt C, et al. Mediterranean spotted fever mimicking Kawasaki disease. BMJ. Mar 1 1997;314(7081):655-6. [Medline].

  10. Jensenius M, Fournier PE, Raoult D. Tick-borne rickettsioses in international travellers. Int J Infect Dis. May 2004;8(3):139-46. [Medline].

  11. La Scola B, Raoult D. Diagnosis of Mediterranean spotted fever by cultivation of Rickettsia conorii from blood and skin samples using the centrifugation-shell vial technique and by detection of R. conorii in circulating endothelial cells: a 6-year follow-up. J Clin Microbiol. Nov 1996;34(11):2722-7. [Medline].

  12. Raoult D, Soulayrol L, Toga B, et al. Babesiosis, pentamidine, and cotrimoxazole. Ann Intern Med. Dec 1987;107(6):944. [Medline].

  13. Rolain JM, Jensenius M, Raoult D. Rickettsial infections--a threat to travellers?. Curr Opin Infect Dis. Oct 2004;17(5):433-7. [Medline].

  14. Shazberg G, Moise J, Terespolsky N, et al. Family outbreak of Rickettsia conorii infection. Emerg Infect Dis. Sep-Oct 1999;5(5):723-4. [Medline].

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Further Reading

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Keywords

Mediterranean spotted fever, boutonneuse fever, Crimean fever, Kenya fever, Rhipicephalus sanguineus, tache noire, Rickettsia conorii, Marseilles fever, Kenya tick typhus, African tick bite fever, Indian tick typhus, Israeli tick typhus, rickettsiosis

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Contributor Information and Disclosures

Author

Jason F Okulicz, MD, Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Staff, Infectious Disease Service, Brooke Army Medical Center
Jason F Okulicz, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Mark S Rasnake, MD, 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 is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, and 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, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Joseph Richard Masci, MD, Chief of Infectious Diseases, Associate Director, Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, Elmhurst Hospital Center, Mount Sinai School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD, Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Association of Professors of Medicine, Association of Program Directors in Internal Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

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