Fatal Rickettsia Infection Presenting With Acute Respiratory Distress, Sepsis, Thrombocytopenia, and Encephalopathy: A Case Report

Rocky Mountain spotted fever (RMSF) is one of the most common tick-borne rickettsial diseases in the USA. It is caused by the bacterium Rickettsia rickettsii, which is found in most states. It tends to be fatal even in otherwise healthy people. The diagnosis of RMSF is difficult because of the non-specific, wide-ranging presentations of the disease, especially early in its course, when symptoms may begin with a mild fever, headache, and rash after three or more days of illness, and may progress to fulminant disease. Prompt empirical antimicrobial therapy and aggressive supportive care are mandatory to avoid life-threatening complications, and treatment should not be delayed while awaiting diagnostic confirmation. We present a case of a 62-year-old male who presented with confusion and multiple falls, later developing a maculopapular rash. The initial non-specific symptoms contributed to a delay in diagnosis. Complicating management further, the patient has a documented allergy to doxycycline, the first-line treatment for RMSF. This case underscores the importance of early clinical suspicion and the unique challenges in managing RMSF in patients with a contraindication to standard therapy.