Pneumonia with no eschar: an atypical presentation of rickettsial disease

A middle-aged male construction worker presented with a 7-day history of fever, night sweats and malaise, unresponsive to oral cefuroxime. He developed pale stools and dark urine but denied abdominal pain or neurological symptoms. Examination revealed mild jaundice with stable vital signs and no focal findings. Laboratory tests showed markedly elevated C-reactive protein, thrombocytopenia and significantly deranged liver enzymes. Extensive infectious workup was negative except for a positive PCR for <i>Rickettsia</i> species. Imaging revealed a right upper lobe consolidation on CT, though chest X-ray was initially normal. He was empirically treated with doxycycline before confirmation of rickettsial infection, based on the clinical picture. The patient's symptoms and liver function improved with doxycycline, supporting the diagnosis of a systemic rickettsial illness with hepatic and pulmonary involvement. This case is notable for the rare pulmonary involvement in rickettsial infection along with the absence of the typical rickettsial rash or eschar, both of which highlight the diagnostic challenge in this case.