Snapshot 12-year-old boyscout who returned from a summer camping trip in Oklahoma one week ago presents with fever, lethargy, headache, and abdominal pain. Petechial lesions are noted on the palms of his hands and feet. Introduction Rocky Mountain Spotted Fever is a disease caused by infection with Rickettsia rickettsii Transmitted by the American dog tick (Dermacentor variabilis) Name is misleading, as the disease is also endemic to the U.S East Coast Oklahoma and North Carolina have the highest incidence. Life cycle organism is transmitted via tick bite invades the endothelial lining of capillaries causes a small vessel vasculitis, as evidenced by the petechial rash Incubation time following a bite ranges from 2 to 12 days before patients have symptoms Presentation Symptoms prodrome includes headache malaise fever rash appears 2-6 days later on the extremities (wrists/ankles) spreads centrally to palms/soles and trunk Physical exam erythematous maculopapular rash appears rash may lead to cutaneous necrosis altered mental status and/or coma may be observed in late stages Evaluation Diagnosis is primarily clinical based on fever, rash, and history of tick exposure Indirect immunoflourescence of skin biopsy may identify pathogen Serologies may identify immune response to Rickettsia rickettsii Differential Meningococcemia, Lyme Disease, endocarditits, hemorrhagic fever (Ebola, Hanta), vasculitis Treatment Medical doxycycline indications first-line therapy in the treatment of Rocky Mountain Spotted Fever (RMSF) for non-pregnant adults and children chloramphenicol indications used in treatment of RMSF in pregnant women and those with severe adverse reactions to doxycycline (e.g., toxic epidermal necrolysis) Prognosis, Prevention, and Complications Prognosis good to excellent when identified and treated early poor to fatal when detected late Prevention increased awareness of tick bite exposure Complications may lead to coma and death when identified too late