Rocky Mountain Spotted Fever Clinical Presentation

  • Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD   more...
 
Updated: Sep 14, 2011
 

History

People with RMSF generally present within a week after a tick bite. Physicians must maintain a high index of suspicion for Rocky Mountain spotted fever (RMSF) in patients with the following:

  • Febrile illness
  • History of potential tick exposure
  • Travel to endemic area
  • Presentation in the spring or fall

RMSF should be considered in patients with unexplained febrile illness even if they have no history of a tick bite or travel to an endemic area. History of a tick bite is reported by only 70% of patients. (Most tick bites are painless and may be in hidden areas of the body.)

In a case series by Buckingham et al, of 92 patients eventually diagnosed with RMSF, the median delay between first visiting a health care provider and starting antirickettsial therapy was 5 days. Only 49% of the patients reported a tick bite.[13]

In other studies, 66% of reported cases of RMSF included a history of tick attachment 14 days prior to illness. An additional 26% of patients reported being in a tick-infested area.

The classic clinical triad of fever, headache, and rash may be present in less than 5% of patients in the first 3 days of illness but increases to 60-70% by the second week after tick exposure. The absence or delayed appearance of a rash increases the difficulty of diagnosis.

The most common symptom complaints include the following:

  • Fever greater than 102°F - 94% of reported cases
  • Fever within 3 days after tick bite - 66% of reported cases
  • Headache, frequently severe - 86% of reported cases
  • Myalgias - 85% of reported cases
  • CNS symptoms - 25% of patients develop signs of encephalitis (ie, confusion, lethargy); this may progress to stupor, delirium, seizures, or coma
  • GI symptoms - Some patients present with anorexia, nausea, vomiting, diarrhea, and abdominal pain

Patients may also report insomnia and photophobia.

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Physical Examination

Rocky Mountain spotted fever (RMSF) presents with a wide clinical spectrum, ranging from mild fever (usually greater than , headache, and myalgia to disseminated intravascular coagulation (DIC; 32-53% of patients), shock (7-17%), hypotension (17%), and death (4-8%).

Adults tend to present with typical symptoms. Fever with relative bradycardia is the rule. In mild, untreated cases, the fever subsides at the end of the second week.

Skin

Rash is a major diagnostic sign that appears in a low percentage of patients on the first day of infection and in only 49% of patients during the first 3 days.

In 88-90% of RMSF cases, the maculopapular rash appears 2-6 days after onset of fever and progresses through stages and distribution that are never pathognomonic. The rash begins as a maculopapular eruption on the wrists and ankles and spreads centripetally to involve the trunk and extremities.

Classic distribution of RMSF rash on the palms and soles occurs relatively late in the course, appearing in 43% of patients only after the fifth day of symptoms. (The hands and the feet are both involved 49-74% of the time.) Some reports have documented 36-80% of patients with RMSF lack the classic distribution of rash on the palms and soles. (See the images below.)

The palm of a patient with Rocky Mountain spotted The palm of a patient with Rocky Mountain spotted fever exhibiting the classic petechial rash associated with the disease. Courtesy of Sadhana Sathe, MD, PhD. The petechial rash of Rocky Mountain spotted feverThe petechial rash of Rocky Mountain spotted fever affecting the sole and the dorsum of the patient's foot. Courtesy of Sadhana Sathe, MD, PhD.

The face is usually spared. Involvement of the scrotum or the vulva is a diagnostic clue. Nonproductive cough may accompany the rash (33%).

In the early phases, the rash may be blanching, nonpruritic, and macular. In 45-49% of patients, it eventually becomes petechial; in rare cases, purpura and skin necrosis or gangrene develop. In dark-skinned patients, the rash is difficult to see.

The rash is absent at presentation in 10-15% of patients. RMSF without a rash (ie, spotless RMSF) should be considered ehrlichiosis until proven otherwise. Spotless fever is not synonymous with mild or early illness, because substantial proportions of the deaths occur in patients without a rash.

In older patients and in severe or fatal cases of RMSF, the rash tends to appear later and with less frequency.

Other cutaneous abnormalities that may develop in RMSF include postinflammatory hyperpigmentation, jaundice, and mucosal ulcers. An erythema migrans–like rash has also been reported.

Head, ears, eyes, nose, and throat

Conjunctival suffusion develops in 30% of patients. Bilateral edema is present. Periorbital edema is a key diagnostic finding, especially in children. Transient deafness occurs in 7% of patients.

Cardiovascular

Cardiovascular presentations of RMSF can include the following:

  • Myocarditis
  • Relative bradycardia
  • Arrhythmias - Present in 7-16% of patients
  • Hypotension - Occurs in 7-17% of patients

RMSF is the only tick-borne disease that can directly cause congestive heart failure secondary to myocarditis (5-26%).

Pulmonary

Pulmonary edema occurs in severe cases. Pneumonitis is present in 12-17% of patients.[14]

Gastrointestinal

GI presentations of RMSF can include the following:

  • Anorexia
  • Abdominal pain and tenderness (diffuse in right upper quadrant) - Present in 34-52% of patients
  • Jaundice - Develops in severe cases; it is found in 8-9% of patients
  • Hepatomegaly and splenomegaly - Occur in 12-15% and 14-16% of cases, respectively
  • Diarrhea - Develops in 19-20% of patients
  • Increased aspartate aminotransferase (AST) levels - Present in 36-62% of patients

Musculoskeletal

Musculoskeletal presentations of RMSF can include the following:

  • Severe myalgia - Especially in the legs, abdomen, and back; occurs in 72-82% of patients
  • Diffuse arthralgias
  • Edema on the dorsum of the hands and feet - A key sign; occurs in 18-20% of patients
  • Lymphadenopathy - Develops in 27% of cases

Central nervous system

CNS presentations can include the following:

  • Restlessness and irritability
  • Altered mental status - May include delirium, lethargy, and coma
  • Photophobia
  • Meningoencephalitis (confusion, seizures [8%], focal neurologic deficits)
  • Cranial neuropathies
  • Urinary or fecal incontinence
  • Ataxia - Present in 5-18% of cases
  • Meningismus - Develops in 18% of patients
  • Cranial nerve palsies
  • Hearing loss
  • Photophobia
  • Severe vertigo
  • Dysarthria
  • Aphasia
  • Hemiplegia, paraplegia, or complete paralysis
  • Nystagmus
  • Hyperreflexia
  • Spasticity
  • Fasciculations

Eyes

The incidence of ocular changes in RMSF is considered low but probably is underestimated. Such changes can include petechial conjunctivitis, which occurs as part of the generalized rash, and anterior uveitis.

Retinal vascular dysfunction may result in retinal hemorrhages, retinal ischemia manifested by cotton-wool spots and nerve fiber layer hemorrhages, retinal vascular engorgement and tortuosity, and branch retinal arteriolar occlusion.

Optic disc edema due to ischemia and inflammation and orbital edema from increased extravascular volume may be present. Optic disc edema may be associated with peripapillary subretinal fluid extending into the macula (neuroretinitis).

Additional presentations

Miscellaneous presentations include dehydration, generalized edema, and chills. Effects of disseminated R rickettsii infection of endothelial cells include increased vascular permeability that leads to edema, hypovolemia, hypotension, and prerenal azotemia.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Marie Spevak O'Brien, DO  Assistant Clinical Professor of Medicine, Arthritis and Rheumatology, Lehigh Valley Physician Group

Marie Spevak O'Brien, DO is a member of the following medical societies: American College of Physicians, American College of Rheumatology, American Medical Association, American Osteopathic Association, International Society for Clinical Densitometry, and Pennsylvania Medical Society

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 Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Allon Amitai, MD International Emergency Medicine Fellow, Rhode Island Hospital; Consulting Staff, Memorial Hospital of Rhode Island; Doctoring Preceptor, Brown University Medical School

Allon Amitai, MD is a member of the following medical societies: American College of Emergency Physicians

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.

Peter MC DeBlieux, MD Professor of Clinical Medicine and Pediatrics, Section of Pulmonary and Critical Care Medicine, Program Director, Department of Emergency Medicine, Louisiana State University School of Medicine in New Orleans

Peter MC DeBlieux, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Radiological Society of North America, and Society of Critical Care Medicine

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.

Aaron Glatt, MD Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, St Joseph Hospital (formerly New Island Hospital)

Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society forHealthcareEpidemiology of America

Disclosure: Nothing to disclose.

Gary L Gorby, MD Associate Professor, Departments of Internal Medicine and Medical Microbiology and Immunology, Division of Infectious Diseases, Creighton University School of Medicine; Associate Professor of Medicine, University of Nebraska Medical Center; Associate Chair, Omaha Veterans Affairs Medical Center

Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Jon Mark Hirshon, MD, MPH Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Christopher D Johnson, MD Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate Medical Center College of Medicine

Disclosure: Nothing to disclose.

Rajendra Kapila, MD, MBBS Associate Professor, Department of Medicine, University of Medicine and Dentistry of New Jersey-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.

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.

Byron L Lam, MD Professor, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine

Byron L Lam, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Richard Medlin, Jr, MD Consulting Staff, Department of Anesthesiology, Emory University Hospital

Richard Medlin, Jr, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

Jeffrey Meffert, MD Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at 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.

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Noah S Scheinfeld, MD, JD, FAAD Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, and 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

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.

John D Sheppard Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, American Uveitis Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Richard H Sinert, DO Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Snyder, MD Vice-Chair, Program Director, Department of Medicine, Norfolk General Hospital; Clinical Associate Professor, Department of Internal Medicine, East Virginia Medical School

Richard H Snyder, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Marie Spevak O'Brien, DO Assistant Clinical Professor of Medicine, Arthritis and Rheumatology, Lehigh Valley Physician Group

Marie Spevak O'Brien, DO is a member of the following medical societies: American College of Physicians, American College of Rheumatology, American Medical Association, American Osteopathic Association, International Society for Clinical Densitometry, and Pennsylvania 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

R Christopher Walton, MD Professor, Director of Uveitis and Ocular Inflammatory Disease Service, Department of Ophthalmology, Assistant Dean for Graduate Medical Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital

R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society

Disclosure: Nothing to disclose.

References

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The palm of a patient with Rocky Mountain spotted fever exhibiting the classic petechial rash associated with the disease. Courtesy of Sadhana Sathe, MD, PhD.
The petechial rash of Rocky Mountain spotted fever affecting the sole and the dorsum of the patient's foot. Courtesy of Sadhana Sathe, MD, PhD.
 
 
 
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