• Matthew E Ravish, Daniel P Krowchuk, Michael Zapadka, and Avinash K Shetty.
• Department of Pediatrics, Wake Forest University School of Medicine and Brenner Children's Hospital, Winston-Salem, North Carolina 27157, USA.
• J Emerg Med. 2013 Aug 1;45(2):186-9.

BackgroundRocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes.ObjectiveOur aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF.MethodsWe report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection.ConclusionsWe present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.Copyright © 2013 Elsevier Inc. All rights reserved.

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