Rickettsialpox Clinical Presentation

  • Author: Julie A Ake, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Nov 28, 2011
 

History

  • Following a mite bite, R akari proliferates locally in the skin. After 7-10 days, a firm, red papule 1-1.5 cm in diameter appears; in a few days, it vesiculates with a surrounding area of erythema. The lesion then ulcerates, forms an eschar, and slowly heals.
  • About 3-7 days after the appearance of the skin lesion, rickettsialpox may manifest as a sudden onset of high fever, chills, sore throat, rigor and profuse sweating, myalgias (especially backache), anorexia, and photophobia. Untreated, fever may last a week. Vertigo, conjunctival injection, cough, rhinorrhea, nausea, and vomiting sometimes occur. Headaches and neck stiffness may be severe. Regional lymphadenopathy at the draining site of the eschar is common, and generalized lymphadenopathy has also been reported. Lymphangitis is not a feature of rickettsialpox.
  • Approximately 2-3 days after the onset of systemic symptoms, the generalized papulovesicular rash of rickettsialpox erupts. This can involves palms and soles and is occasionally accompanied by an oropharyngeal enanthem. This rash typically lasts a week.
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Physical

  • Patients may have high fever fluctuating between 101-104ºF.
  • The maculopapulovesicular exanthema is usually comprised of 20-40 lesions but may range from 5-100.
    • The lesions typically begin as papules with subsequent vesiculation, but may remain avesicular.
    • Lesions are usually scattered on the face, trunk, and extremities with no particular sequence of involvement. Patients may present with lesions on the tongue, buccal mucosa, and pharynx.
    • Lesions may also be present on palms and soles.
    • The lesions are typically asymptomatic but can be pruritic.
    • Rashes last a week. Scabs form but do not leave scars.
  • At the time of presentation, an eschar is present in at least 95% of affected individuals. The mite bite is painless and begins as an erythematous papule, which develops into a tense vesicle that ruptures to form a dark crust with surrounding induration. More than one eschar may be present.
    • Mite bites can occur on any part of the body, including the hands, feet, face, and angle of the mouth (labial commissure). They do occur in covered areas.
    • Regional adenopathy may be present and is usually tender.
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Causes

  • Rickettsialpox is caused by R akari and was first described in 1946.
  • Rickettsialpox is sporadically observed in many urban centers of the United States. The bloodsucking mite L sanguineus is the vector, and mice (typically M musculus) and other rodents are the reservoir.
  • When murine hosts are scarce, A sanguineus will bite humans.
  • No human-to-human transmission occurs.
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Contributor Information and Disclosures
Author

Julie A Ake, MD  Fellow, Infectious Disease Service, Walter Reed Army Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Timothy J Whitman, DO  Consulting Staff, Department of Infectious Disease, National Naval Medical Center

Disclosure: Nothing to disclose.

Chi Hiong U Go, MD  Assistant Professor, Department of Internal Medicine, Texas Tech University Health Science Center at Odessa

Chi Hiong U Go, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred A Lopez, MD  Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD 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, and Louisiana State Medical Society

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

Charles V Sanders, MD  Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physician Executives, American College of Physicians, American Federation for Medical Research, American Foundation for AIDS Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Baxter International and Johnson & Johnson Royalty Other

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

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.

References

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Table. Characteristics of Similar Conditions
DiseaseRash/EscharGeneralized RashClinical FeaturesGeography
Rickettsialpox secondary to R akari infectionA red papule with a vesicle in the center dries and forms a black eschar with surrounding induration. Multiple eschars are possible.The papulovesicular rash is usually on the trunk and extremities; the palms, soles, and oral mucosa may also be involved.The papule precedes the febrile illness and mild systemic symptoms. Regional lymphadenopathy may develop.See Frequency
Chickenpox secondary to varicella zoster infectionThe papule turns into a vesicle on an erythematous base and resembles a "dew drop on a rose petal."The rash begins on the head and progresses to the trunk, arms, and then legs; vesicles are present in all stages.It is common in children. No black eschar is present.Worldwide
Mediterranean spotted fever secondary to Rickettsia conorii infectionAt the site of a tick bite, a single eschar with a red halo forms.The rash is generalized, involves the palms and soles, and is often maculopapular, occasionally petechial.Fever, headache, myalgias may develop. The onset is abrupt. The disease may be severe in context of comorbidity.North Africa, Middle East, Southern Europe
African tick bite fever secondary to R africae infectionSingle or multiple eschars with regional lymphadenopathyA scant generalized rash, vesicular or maculopapular, may be present. Conversely, the rash may be absent.Fever, headache, myalgias, regional lymphadenopathy; associated with reports of subacute neuropathySub-Saharan Africa, Caribbean
Human spotted fever secondary to R parkeri infectionSingle or multiple eschars develop from erythematous papules.Scant nonpruritic papulesFever, headache, myalgias, arthralgiasUnited States
Scrub typhus secondary to Orientia tsutsugamushi infectionA vesicle or black scab appears on an erythematous base at the bite site.Vesicles are usually on the trunk or extremities.The rash fades within a few days; pneumonitis is common.Asia-Pacific rim
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