Fever and rash after holidays in the Mediterranean basin - Mediterranean spotted fever (Boutonneuse fever)

History and clinical findings: In connection with a period of residence in the Mediterranean basin (Portugal, Spain, Sicily) one woman and two men (ag e: 28, 31 and 40 years) got sick with fever in August and in the midst of O ctober. In addition, they complained about headache in two cases and myalgi as, arthralgia and vomiting in one case, respectively. Two of the vacatione rs (cases 2 and 3) had been accompanied by their dogs. One of them (case 2) was bitten of a tick. The woman (case 3) removed few days after vacation-b eginning ticks from her dogs. Patients 1 and 2 appeared severely ill and pr esented with high fever and generalized maculopapular rash which included a lso the soles and palms. Patients 2 and 3 had a primarily-lesion ("eschar") . in patient 3 the eschar was pustular and associated with regional lymphad enitis. Investigations: All three patients showed an increased erythrocyte sediment ation rate and elevated liver enzymes. Cases 1 and 2 presented with a signi ficantly elevated activity of lactate dehydrogenase, leukocyturia and micro hematuria. Indirect immunofluorescent assay for specific antibodies directe d against Rickettsia conorii revealed titers between 1:40 and 1:640 (normal : negative). Diagnosis, treatment and course: Diagnosis was based on the triad fever, ra sh and eschar as well as on epidemiological data which include a recent per iod of residence in the Mediterranean basin during the summer and contact w ith a dog. In case 1 diagnosis was difficult because of the absence of an e schar. This patient had been treated with penicillin for two days without s uccess. Only the parenteral administration of ciprofloxacin caused complete defervescence and clinical improvement within two days. A complete deferve scence within two days was reached with doxycycline also in case 2. In comp arison to these cases, the course in the third patient was mild, and the pa tient defervesced spontaneously. Conclusion: Mediterranean spotted fever should be considered in the case of unclear fever and rash following a period of residence in the Mediterranea n basin during summer time. An eschar may confirm this diagnosis, and early start of therapy may shorten the course of the disease and prevent complic ations.