Rocky Mountain Spotted Fever: Missed opportunities for early treatment

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Buckingham et al from six institutions in the southeastern and south-central United States pooled 92 hospitalized cases of Rocky Mountain Spotted Fever (RMSF) to permit re-assessment of the disease, management, and outcome 30 years after the last large case series. Although this retrospective series has limitations of undoubted low case ascertainment and probable low symptom/sign ascertainment, the major findings stand alone. The infection and potential for morbid or fatal outcome of RMSF has not changed, and physicians continue to miss opportunities for early diagnosis. Although 86% of patients in the series had been taken for medical care prior to hospitalization, RMSF had not been suspected or treated in most patients. Treatment of RMSF should be begun empirically on the basis of clinical suspicion. The challenge for physicians is consideration of the diagnosis. Buckingham et al report an incomplete classic constellation of symptoms in most patients at first outpatient evaluation (median of 2 days of illness), as well as in 58% of patients at the time of hospitalization and first anti-rickettsial antimicrobial therapy (median of 7 days of illness). The finding in this study that a medical outpatient visit early in the course of illness was significantly associated with delay in therapy reminds us that barring another diagnosis, patients with febrile illnesses have diseases and diagnoses “in-progress” (rather than diagnoses of viral illnesses) requiring continuous re-thinking as the course evolves.

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