Diagnosis: Rocky Mountain Spotted Fever

NYTimes

October 9, 2005
Sleuthing a Rash
By LISA SANDERS, M.D.

1. Symptoms

"I always heard that when your palms itched it meant you were coming into money." The patient smiled faintly as the doctor entered the examining room. "No money so far," she continued, "but lots of fever." The doctor eyed her attentively. He'd known the patient for years and despite her playful tone, today she looked really sick.

She'd been well until a few days earlier, she told him. She had a little pain when she went to the bathroom, which made her think she had a urinary-tract infection, and she increased her fluids. When that hadn't helped, she had come to the office and seen a different doctor, who started her on an antibiotic and a painkiller. She didn't get better; in fact, that's when she first noticed the itchy palms. The next morning she was so achy she could barely get out of bed. That night, she had shaking chills and a fever of 102.

The rash appeared the following day. It started on her arms, her face and her chest. She stopped taking the painkiller, thinking the rash could be an allergic reaction to it, she told him. But the rash just kept spreading.

Dr. Davis Sprague was worried. The patient was 57, and other than a back injury a few years ago and some well-controlled high blood pressure, she had always been healthy. Not today. He was glad she was the last patient of the day because he could tell this was going to take time.

On examination she looked tired, and her face was flushed and sweaty. Her short, dark hair lay plastered to her scalp. She had no fever, but her blood pressure was quite low, and her heart was beating unnaturally fast. The rash that now covered her body was made up of hundreds of small, flat red marks. The newest ones, those on her legs, were like red-colored freckles. The ones on her arms and chest were larger - maybe the size of nickels - and less well defined. The rash didn't itch or hurt. The palms of her hands were itchy and reddened but rash-free. A urine sample showed no evidence of bacteria or white cells but was positive for blood. That might have been a result of the fever, or it could indicate kidney damage.

2. Investigation

"You need to go to the emergency room," Sprague instructed the patient. "You may even need to be admitted to the hospital. I'm not sure what you've got, but I am pretty sure that you're sick." If she had developed an allergy to one of the medicines she was taking, he explained, it could be serious and might even require other medications. What he was really worried about, though, was that she had some sort of infection that was spreading throughout her body. In the E.R. they would be able to test her blood and get a better sense of what was going on.

The doctor in the emergency room ordered what seemed like an endless stream of blood tests as well as a chest X-ray. But when all the tests came back normal, he decided she was well enough to go home. It probably was an allergic reaction, he told her, and gave her a different antibiotic. She should follow up with her doctor in a couple of days.

Two days later, she was back at her doctor's office. She did feel a little better, she said, but she was still having fevers, and now she felt short of breath with even minimal effort. "What do you think is going on?" she asked.

Sprague wasn't sure. Maybe the E.R. doctors had been right, and it really was an allergy - she was a little better since they'd changed the antibiotics. But the shortness of breath started after that. He was still worried about infection. Fever and rash were common symptoms. It could be a viral illness - coxsackie? West Nile? Or was it bacterial? These symptoms, he told her, were so nonspecific they could be found in everything from garden-variety Lyme disease to something really exotic like Rocky Mountain spotted fever. "We may never figure it out," he confessed. But since she was getting better, he was willing to give her a few more days. If she was still spiking fevers then, he'd send off some blood work to try to find an answer.

At home, though, the patient continued to worry. That night she sat down at the computer to do a little research of her own. "Rash, adult, fever," she Googled.

When you Google a set of symptoms, you don't get the most common or the most likely diseases; you get the diseases with the greatest number of links from other Web sites. Her Google search brought up dozens of fairly unusual, but well-linked, illnesses: coccidioidomycosis - a fungal infection most common on the West Coast; dengue fever - endemic to the tropics and near tropics; measles; scarlet fever.

But the patient immediately focused on the first result: Rocky Mountain spotted fever, which her doctor had mentioned. As she read about the disease, she began to feel a little panicky. The description of the symptoms, she said, fit her perfectly: the rash, the fever, the muscle aches. The rash, she read, can involve the palms of the hands, which is pretty unusual. She didn't have a rash there, but her palms were red and itchy. Also, the disease is transmitted by dog ticks - she had a dog. It's most common in the summer - it was August. Though it's rare, it is more commonly seen on the East Coast than in the Rockies, and she was in upstate New York. People can die from this disease, she read. It's the deadliest of all the tick-borne illnesses.

She called the emergency room where she had been seen. Had they tested her for Rocky Mountain spotted fever? No, she was told, why would they? They had never seen a single case in the area. She hung up feeling somewhat relieved. They didn't think it was Rocky Mountain spotted fever; Dr. Sprague didn't think it was. Chances are that it wasn't.

Over the next few days, the patient started to feel almost normal again. The rash was fading - though now it itched like crazy - and her energy was coming back. But she continued to have fevers at night and still occasionally felt short of breath. She returned to Sprague's office one more time. "I'm glad to hear you're feeling better, but these fevers worry me," he said. "I want to send off some tests." He would recheck her blood count - an elevated white-blood count would suggest an infection. He would check her liver and kidney functions. And he would send off a test for Lyme. It's a disease that can present in many ways, and it's common in the area.

3. Resolution

"What about Rocky Mountain spotted fever?" the patient asked. She confessed that she had looked it up on the Internet and thought the symptoms were close to what she had. The doctor thought for a moment. "I don't think that's what you have, but let's add it." He had heard doctors complain about their patients surfing the Web for diagnoses, but he didn't usually mind. He had never seen Rocky Mountain spotted fever - maybe she was right.

The results came back a few days later. "You're an internist's dream," the doctor sang out as he entered the examining room. "It really is Rocky Mountain spotted fever, and I would have completely missed it if I hadn't listened to you." He started the patient on Doxycycline - the antibiotic of choice for this bacterium. Her body seemed to be fighting off the illness without it, but he wasn't taking any chances.

I spoke to the patient not long ago. She is still recovering from the infection. The fevers are completely gone, and even her palms are improving. I asked her how she felt about her doctor, who had come so close to missing this diagnosis. "But he didn't miss it. He was the first to think of it. And he sent off the test - even though it could prove him wrong. He just wanted to figure out what was going on. He listened to me. That's exactly the kind of doctor I want."