Rocky Mountain spotted fever

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Rickettsia rickettsii

Scientific classification
Kingdom: Bacteria
Phylum: Proteobacteria
Class: Alpha
Proteobacteria
Order: Rickettsiales
Family: Rickettsiaceae
Genus: Rickettsia
Species: R. rickettsii
Binomial name
Rickettsia rickettsii
Wolbach, 1919
Rocky Mountain spotted fever
Classification & external
resources

ICD-10 A77.0

ICD-9 082.0
DiseasesDB 31130
MedlinePlus 000654
eMedicine emerg/510
med/2043
ped/2709
 oph/503
derm/772

Rocky Mountain spotted fever is the most severe and most frequently reported
rickettsial illness in the United States, and has been diagnosed throughout the Americas.
Some synonyms for Rocky Mountain spotted fever in other countries include “tick
typhus,” “Tobia fever” (Colombia), “São Paulo fever” or “febre maculosa” (Brazil), and
“fiebre manchada” (Mexico). The disease is caused by Rickettsia rickettsii, a species of
bacteria that is spread to humans by hard ticks (Dermacentor). Initial signs and symptoms
of the disease include sudden onset of fever, headache, and muscle pain, followed by
development of rash. The disease can be difficult to diagnose in the early stages, and
without prompt and appropriate treatment it can be fatal.

The name “Rocky Mountain spotted fever” is somewhat of a misnomer. Beginning in the
1930s, it became clear that this disease occurred in many areas of the United States other
than the Rocky Mountain region. It is now recognized that this disease is broadly
distributed throughout the continental United States, and occurs as far north as Canada
and as far south as Central America, Mexico, and parts of South America. Between 1981
and 1996, this disease was reported from every U.S. state except Hawaii, Vermont,
Maine, and Alaska.

Rocky Mountain spotted fever remains a serious and potentially life-threatening

infectious disease today. Despite the availability of effective treatment and advances in
medical care, approximately 3% to 5% of individuals who become ill with Rocky
Mountain spotted fever still die from the infection. However, effective antibiotic therapy
has dramatically reduced the number of deaths caused by Rocky Mountain spotted fever;
before the discovery of tetracycline and chloramphenicol in the late 1940s, as many as
30% of persons infected with R. rickettsii died.

Contents
[hide]

• 1 Natural history
• 2 Epidemiology
• 3 Signs and symptoms
• 4 Treatment
• 5 History

• 6 External links

[edit] Natural history

Rocky Mountain spotted fever, like all rickettsial infections, is classified as a zoonosis.
Zoonoses are diseases of animals that can be transmitted to humans. Many zoonotic
diseases require a vector (e.g., a mosquito, tick, or mite) in order to be transmitted from
the animal host to the human host. In the case of Rocky Mountain spotted fever, ticks are
the natural hosts, serving as both reservoirs and vectors of R. rickettsii. Ticks transmit the
organism to vertebrates primarily by their bite. Less commonly, infections may occur
following exposure to crushed tick tissues, fluids, or tick feces.

The life cycle of Dermacentor variabilis and Dermacentor andersoni ticks (Family
Ixodidae)

A female tick can transmit R. rickettsii to her eggs in a process called transovarial
transmission. Ticks can also become infected with R. rickettsii while feeding on blood
from the host in either the larval or nymphal stage. After the tick develops into the next
stage, the R. rickettsii may be transmitted to the second host during the feeding process.
Furthermore, male ticks may transfer R. rickettsii to female ticks through body fluids or
spermatozoa during the mating process. These types of transmission represent how
generations or life stages of infected ticks are maintained. Once infected, the tick can
carry the pathogen for life.

Rickettsiae are transmitted to a vertebrate host through saliva while a tick is feeding. It
usually takes several hours of attachment and feeding before the rickettsiae are
transmitted to the host. The risk of exposure to a tick carrying R. rickettsii is low. In
general, about 1%-3% of the tick population carries R. rickettsii, even in areas where the
majority of human cases are reported.

There are 2 major vectors of R. rickettsii in the United States, the American dog tick and
the Rocky Mountain wood tick. American dog ticks (Dermacentor variabilis) are widely
distributed east of the Rocky Mountains and also occurs in limited areas on the Pacific
Coast. Dogs and medium-sized mammals are the preferred hosts of adult D. variabilis,
although it feeds readily on other large mammals, including humans. This tick is the most
commonly identified species responsible for transmitting R. rickettsii to humans. Rocky
Mountain wood ticks (Dermacentor andersoni) are found in the Rocky Mountain states
and in southwestern Canada. The life cycle of this tick may require up to 2 to 3 years for
completion. Adult ticks feed primarily on large mammals. Larvae and nymphs feed on
small rodents.
Other tick species have been shown to be naturally infected with R. rickettsii or serve as
experimental vectors in the laboratory. However, these species are likely to play only a
minor role in the ecology of R. rickettsii.

[edit] Epidemiology
Rocky Mountain spotted fever has been a reportable disease in the United States since
1918. In the last 50 years, approximately 250-1200 cases of Rocky Mountain spotted
fever have been reported annually, although it is likely that many more cases go
unreported (source: United States Centers for Disease Control). incub Over 90% of
patients with Rocky Mountain spotted fever are infected during April through August.
This period is the season for increased numbers of adult and nymphal Dermacentor ticks.
A history of tick bite or exposure to tick-infested habitats is reported in approximately
60% of all cases of Rocky Mountain spotted fever.

Over half of U.S. Rocky Mountain spotted fever infections are reported from the south-
Atlantic region of the United States (Delaware, Maryland, Washington D.C., Virginia,
West Virginia, North Carolina, South Carolina, Georgia, and Florida). Infection also
occurs in other parts of the United States, namely the Pacific region (Washington,
Oregon, and California) and west south-central (Arkansas, Louisiana, Oklahoma, and
Texas) region.

The states with the highest incidences of Rocky Mountain spotted fever are North
Carolina and Oklahoma; these two states combined accounted for 35% of the total
number of U.S. cases reported to CDC during 1993 through 1996. Although Rocky
Mountain spotted fever was first identified in the Rocky Mountain states, less than 3% of
the U.S. cases were reported from that area during the same interval (1993-1996).

The frequency of reported cases of Rocky Mountain spotted fever is highest among
males, Caucasians, and children. Two-thirds of the Rocky Mountain spotted fever cases
occur in children under the age of 15 years, with the peak age being 5 to 9 years old.
Individuals with frequent exposure to dogs and who reside near wooded areas or areas
with high grass may also be at increased risk of infection.

Infection with Rickettsia rickettsii has also been documented in Argentina, Brazil,
Colombia, Costa Rica, Mexico, and Panama. Closely related organisms cause other types
of spotted fevers in other parts of the world.

[edit] Signs and symptoms

Petechial rash caused by rocky mountain spotted fever on the arm

Rocky Mountain spotted fever can be very difficult to diagnose in its early stages, even
among experienced physicians who are familiar with the disease.

Patients infected with R. rickettsii generally visit a physician in the first week of their
illness, following an incubation period of about one to two weeks after a tick bite. The
early clinical presentation of Rocky Mountain spotted fever is nonspecific and may
resemble a variety of other infectious and non-infectious diseases.

Initial symptoms may include:

• fever
• nausea
• emesis
• severe headache
• muscle pain
• lack of appetite

Later signs and symptoms include:

• maculopapular rash
• petechial rash
• abdominal pain
• joint pain

The classic triad of findings for this disease are fever, rash, and history of tick bite.
However, this combination is often not identified when the patient initially presents for
care.

The rash first appears 2-5 days after the onset of fever and is often not present or may be
very subtle when the patient is initially seen by a physician. Younger patients usually
develop the rash earlier than older patients. Most often it begins as small, flat, pink, non-
itchy spots (macules) on the wrists, forearms, and ankles. These spots turn pale when
pressure is applied and eventually become raised on the skin. The characteristic red,
spotted (petechial) rash of Rocky Mountain spotted fever is usually not seen until the
sixth day or later after onset of symptoms, and this type of rash occurs in only 35% to
60% of patients with Rocky Mountain spotted fever. The rash involves the palms or soles
in as many as 50% to 80% of patients; however, this distribution may not occur until later
in the course of the disease. As many as 10% to 15% of patients may never develop a
rash.

Abnormal laboratory findings seen in patients with Rocky Mountain spotted fever may
include thrombocytopenia, hyponatremia, or elevated liver enzyme levels.

Rocky Mountain spotted fever can be a very severe illness and patients often require
hospitalization. Because R. rickettsii infects the cells lining blood vessels throughout the
body, severe manifestations of this disease may involve the respiratory system, central
nervous system, gastrointestinal system, or renal system. Host factors associated with
severe or fatal Rocky Mountain spotted fever include advanced age, male sex, African-
American race, chronic alcohol abuse, and glucose-6-phosphate dehydrogenase (G6PD)
deficiency. Deficiency of G6PD is a sex-linked genetic condition affecting approximately
12% of the U.S. African-American male population; deficiency of this enzyme is
associated with a high proportion of severe cases of Rocky Mountain spotted fever. This
is a rare clinical course that is often fatal within 5 days of onset of illness.

Long-term health problems following acute Rocky Mountain spotted fever infection
include partial paralysis of the lower extremities, gangrene requiring amputation of
fingers, toes, or arms or legs, hearing loss, loss of bowel or bladder control, movement
disorders, and language disorders. These complications are most frequent in persons
recovering from severe, life-threatening disease, often following lengthy hospitalizations.

[edit] Treatment
Appropriate antibiotic treatment is initiated immediately when there is a suspicion of
Rocky Mountain spotted fever on the basis of clinical and epidemiological findings.
Treatment should not be delayed until laboratory confirmation is obtained.

If the patient is treated within the first 4-5 days of the disease, fever generally subsides
within 24-72 hours after treatment with an appropriate antibiotic (usually a tetracycline).
In fact, failure to respond to a tetracycline antibiotic argues against a diagnosis of Rocky
Mountain spotted fever. Severely ill patients may require longer periods before their
fever resolves, especially if they have experienced damage to multiple organ systems.
Preventive therapy in non-ill patients who have had recent tick bites is not recommended
and may, in fact, only delay the onset of disease.

Doxycycline (For adults, 100 mg every 12 hours. For children under 45 kg [100 lb], 4
mg/kg body weight per day in two divided doses) is the drug of choice for patients with
Rocky Mountain spotted fever. Therapy is continued for at least 3 days after fever
subsides and until there is unequivocal evidence of clinical improvement, generally for a
minimum total course of 5 to 10 days. Severe or complicated disease may require longer
treatment courses. Doxycycline is also the preferred drug for patients with ehrlichiosis,
another tick-transmitted infection with signs and symptoms that may resemble Rocky
Mountain spotted fever.

Chloramphenicol is an alternative drug that can be used to treat Rocky Mountain spotted
fever; however, this drug may be associated with a wide range of side effects and may
require careful monitoring of blood levels (as it can cause aplastic anemia).

[edit] History
Rocky Mountain spotted fever was first recognized in 1896 in the Snake River Valley of
Idaho and was originally called “black measles” because of the characteristic rash. It was
a dreaded and frequently fatal disease that affected hundreds of people in this area. By the
early 1900s, the recognized geographic distribution of this disease grew to encompass
parts of the United States as far north as Washington and Montana and as far south as
California, Arizona, and New Mexico.

Howard T. Ricketts was the first to establish the identity of the infectious organism that
causes this disease. He and others characterized the basic epidemiological features of the
disease, including the role of tick vectors. Their studies found that Rocky Mountain
spotted fever is caused by Rickettsia rickettsii. This species is maintained in nature by a
complex cycle involving ticks and mammals; humans are considered to be accidental
hosts and are not involved in the natural transmission cycle of this pathogen. Tragically—
and ironically—Dr. Ricketts died of typhus (another rickettsial disease) in Mexico in
1910, shortly after completing his remarkable studies on Rocky Mountain spotted fever.

[edit] External links

Wikimedia Commons has media related to:

Rocky Mountain spotted fever

Wikispecies has information related to:

Ixodidae

Wikispecies has information related to:

Rickettsia
 • Association of State and Territorial Directors of Health Promotion and Public
Health Education
• Centers for Disease Control - Rocky Mountain spotted fever

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Bacterial diseases (primarily A00-A79, 001-041,080-109)

Clostridium (Pseudomembranous colitis, Botulism, Tetanus, Gas
gangrene) - Streptococcus A and B (Scarlet fever, Erysipelas) -
G+/Firmicutes
Staphylococcus (Toxic shock syndrome) - Bacilli (Anthrax,
Listeriosis)
Mycobacterium: Tuberculosis (Ghon focus, Ghon's complex,
Tuberculous meningitis, Pott's disease, Scrofula, Bazin disease,
Lupus vulgaris, Miliary tuberculosis) - Leprosy - Lady Windermere
G+/Actinobacteria
syndrome - Buruli ulcer -
Actinomycetales: Actinomycosis - Nocardiosis - Diphtheria -
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G-/Spirochetal
mouth - Lyme disease - Rat-bite fever (Sodoku) - Leptospirosis
G-/Chlamydiae Chlamydia - Lymphogranuloma venereum - Psittacosis - Trachoma
Rickettsioses (Typhus, Scrub typhus, Rocky Mountain spotted
fever, Boutonneuse fever, Q fever, Trench fever, Rickettsialpox) -
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other intestinal (Cholera, Shigellosis) - Zoonotic (Bubonic plague,
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