eMedicine Specialties > Emergency Medicine > Infectious Diseases

Tick-Borne Diseases, Rocky Mountain Spotted Fever: Follow-up

Author: Allon Amitai, MD, International Emergency Medicine Fellow, Rhode Island Hospital; Consulting Staff, Memorial Hospital of Rhode Island; Doctoring Preceptor, Brown University Medical School
Coauthor(s): Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Jan 15, 2008

Follow-up

Further Inpatient Care

  • Seventy-two percent of confirmed cases of RMSF reported to the CDC required hospitalization.
    • Hospitalization occurred a median of 4 days after onset of symptoms.
    • Admit moderately to severely ill patients to the hospital.
    • Admit severely ill patients to the intensive care unit.

Further Outpatient Care

  • RMSF can progress rapidly. Because roughly 10% of outpatients subsequently required admission, close follow-up is necessary if outpatient management is planned.

Deterrence/Prevention

  • No vaccine for RMSF exists, but this disease can be prevented. The populace should avoid areas such as the woods or fields where ticks are found. If this is not possible, the following precautions are suggested:
    • Use tick repellents such as DEET and wear proper clothing, such as long sleeved shirts and pants that fit tightly around your wrists, waist, and ankles. When in the woods, people should check at least twice a day for attached ticks.
    • If a tick is attached, immediate removal may prevent infection. Gently grasp the tick with tweezers as close as possible to the skin and slowly pull it away. If tweezers are not available, fingers covered with tissue paper can be used. Do not attempt to remove the tick with petroleum jelly, hot objects, such as matches or cigarettes, or by other methods. After handling ticks, be sure to wash hands thoroughly with soap and water.
    • Antibiotics are not routinely recommended for the prevention of RMSF in the asymptomatic patient after tick-bite.
    • If fever, headaches, rash, or nausea occurs within 2 weeks of a possible tick bite or exposure, see a doctor immediately.

Complications

  • Data from long-term follow-up studies suggest that significant long-term morbidity is common in patients with severe illness due to RMSF.
  • CNS complications include paraparesis, hearing loss, blindness, peripheral neuropathy, bladder and bowel incontinence, cerebellar, vestibular and motor dysfunction, behavioral problems, and language disorders.
  • Acute renal failure
    • Factors at presentation associated with development of acute renal failure (ARF) included increased bilirubin, advancing age, thrombocytopenia, and the presence of neurological involvement.
    • Age and decreased platelet count at presentation were independently associated with the development of ARF by multivariate analysis.
    • ARF development increased the odds ratio of dying by a factor of 17.
  • Dermatological sequelae
    • Some patients develop minute cicatrices marking the location of focal cutaneous necrosis.
    • In others, progression to digital ischemia occurs transiently or evolves to severe ischemic changes without gangrene. This may result in permanent impairment. Gangrene requiring amputation occurs rarely.

Patient Education

  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Ticks.

Miscellaneous

Medicolegal Pitfalls

  • In endemic areas, a high index of suspicion of RMSF is necessary to prevent delays in diagnosis and treatment.
  • RMSF must be considered in any febrile patient in an endemic area, regardless of atypical presentation, lack of rash, or apparent lack of tick exposure.
  • Most fatalities and permanent disabilities resulting from RMSF are associated with delayed antibiotic therapy.

Special Concerns

  • Pregnancy is a contraindication to doxycycline therapy and mandates admission for chloramphenicol therapy.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack Jr, MD, and previous author, Richard Medlin Jr, MD, to the development and writing of this article.



More on Tick-Borne Diseases, Rocky Mountain Spotted Fever

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Differential Diagnoses & Workup: Tick-Borne Diseases, Rocky Mountain Spotted Fever
Treatment & Medication: Tick-Borne Diseases, Rocky Mountain Spotted Fever
Follow-up: Tick-Borne Diseases, Rocky Mountain Spotted Fever
References
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Further Reading

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Keywords

RMSF, Rickettsia rickettsii, American dog tick, Dermacentor variabilis, D variabilis, Rocky Mountain wood tick, Dermacentor andersoni, D andersoni, myalgias, petechial rash, spotted fevers, encephalitis, confusion, lethargy, stupor, delirium, seizures, coma, Rocky Mountain spotless fever, jaundice, ataxia, cranialnerve palsies, hearing loss, meningismus, photophobia, severe vertigo, dysarthria, aphasia, hemiplegia, paraplegia, complete paralysis, nystagmus, hyperreflexia, spasticity, fasciculations, neurogenic bladder, pulmonary edema, heme-positive stools, Rhipicephalus sanguineus, Amblyomma cajennense

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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 Health Sciences Center
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.

Pharmacy Editor

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

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

 
 
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