CASE PRESENTATION
Thomas E Gibbons, MD: A 24-year-old man with an oral temperature of 39.1 C presented to the emergency department complaining of malaise, rash, and fever. Althoug h he had been seen two days earlier in another emergency department, he had not had a rash at that time. He was told that he probably had an influenza-like illness and he was sent home on aspirin. The following day he developed a fine rash.
Because of his occupation as a construction worker, he was asked about any known exposure to ticks. He remembered that sometime within the previous week he had removed a tick from his arm.
Physical examination revealed a young man in no apparent distress with the following vital signs: temperature, 39.1 C; blood pressure, 126/80 mm Hg; pulse, 110; and respiratory rate, 16. The pupils were equal, round, and reactive. The optic discs were sharp, and no hemorrhages or exudates were visible in the fundi. The tympanic membranes were normal, as was examination of the nose. No intraoral lesions were seen. Examination of the neck was unremarkable. Auscultation of the chest was normal. Cardiac examination revealed a tachycardia without the presence of any robs, gallops, or murmurs. The abdomen was soft to palpation and active bowel sounds were present. The liver was not enlarged and the spleen could not be felt. Neurological examination revealed a normal sensorium with cranial nerves II through XII intact. No deficits were noted in sensation, proprioception, motor function, .coordination, or deep tendon reflexes.
Examination of the skin revealed a fine, erythematous, macular rash distributed over the entire body, including the palms of the hands and soles of the feet. The rash blanched to pressure. Certain areas had coalesced to form larger areas. No vesicules or papules were seen.
Initial laboratory studies included the following: white cell count, 24,000 cells/mL (27 bands, 54 polys, 10 lymphs, and 9 mononuclear cells); hemoglobin, 15.2 gm/dL; and an erythrocyte sedimentation rate of 45 mm/h. A Well-Felix study (Proteus OX-2 and OX-19 antigens) as well as serum for complement fixation studies were drawn initially, but the results would not be available for several days.
The patient was admitted with the presumptive diagnosis of Rocky Mountain spotted fever and was begun on antibiotic therapy with tetracyline. His temperature returned to normal within two days. Because the patient was clinically improving, it was felt that he could be discharged. He continued to take 500 mg tetracycline four times daily, and was closely followed in the Medicine Clinic. Positive confirmation of the diagnosis of Rocky Mountain spotted fever was available on follow-up examination, when the complement