title: A 6-year-old girl with fever, rash, and increased intracranial pressure.
abstract: BACKGROUND
  Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes.
  
  
  OBJECTIVE
  Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF.
  
  
  METHODS
  We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection.
  
  
  CONCLUSIONS
  We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.
authors.affiliation: Department of Pediatrics, Wake Forest University School of Medicine and Brenner Children's Hospital, Winston-Salem, North Carolina 27157, USA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Ravish
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Krowchuk
authors.forename: Michael
authors.initials: M
authors.lastname: Zapadka
authors.forename: Avinash K
authors.initials: AK
authors.lastname: Shetty
mesh_terms: D002648:Child; D005076:Exanthema / Q000175:diagnosis*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007074:Immunoglobulin G / Q000032:analysis; D019586:Intracranial Hypertension / Q000175:diagnosis*; D012284:Rickettsia rickettsii / Q000302:isolation & purification; D012373:Rocky Mountain Spotted Fever / Q000175:diagnosis*
chemical_list: D007074:Immunoglobulin G
keywords: Rocky Mountain spotted fever; fever; raised intracranial pressure; rash