Headaches, chills, fever. . .and then the ER

It was spring in Pennsylvania, and I was seeing a 31-year-old man for the first time. He'd been sick for about three days with headaches, chills, and fever, although his temperature was normal in the office.

He had not had any recent travel, and no one else was sick at home or at work.

The only significant part of his medical history was migraine headaches, and the ones he was having were doozies.

Light hurt his eyes; sound hurt his ears. The only thing that helped his throbbing headaches was ibuprofen, but he had been taking more of it with less relief. He complained that his neck and upper back were stiff, but on exam his range of motion was pretty good; he could put his chin on his chest.

The rest of his physical exam was unremarkable. His throat looked fine, his chest was clear, his heart was regular, and he had no skin rashes.

I diagnosed him with a viral syndrome - an infection with a generic virus expected to run its course uneventfully - and migraines. He left with a prescription for a migraine medication called sumatriptan and instructions to call if he got worse.

Which he did, the next day. The headaches had increased in severity. The fever and chills were back. My physician assistant prescribed amoxicillin, a broad-spectrum antibiotic, over the phone and told him to continue the sumatriptan.

When he was still unimproved the day after that, I added a narcotic agonist/antagonist nasal spray and an antinausea medicine known to help with migraines.

The next day I got a call from the emergency department: My patient had presented with excruciating headache, confusion, and a temperature of 105.6. Yikes! I rushed to the hospital with thoughts of encephalitis and meningitis (infection of the brain and its linings) surging through my mind.

But when I got there his blood pressure, white blood cell count, and platelets were all completely normal, and his neck still wasn't stiff. They had already done a spinal tap, and that too was unremarkable.

When I went in to see him, he was lying on a gurney, curled up on his side, facing away from me, barely covered with a sheet. His bare feet stuck out and I saw something on the soles of his feet that stopped me in my tracks.

I asked him a question.

What I saw on the soles of my patient's feet were blanching red spots called petechiae. There are very few rashes that appear on the palms and soles, and few of those are petechial.

"Have you been bitten by a tick recently?" I asked.

"Oh, my God, yes," shouted his wife. "Right in the middle of his chest, last week."

Sure enough, there was a small red spot I had missed on my initial examination.

Rocky Mountain spotted fever (RMSF) is a tick-borne illness caused by a germ called Rickettsia ricketsiithat causes a petechial rash, typically beginning on the wrists and ankles, then quickly moving to the palms and soles. It is accompanied by high fevers and headaches noted to be particularly excruciating.

The history of migraines had been a complete red herring.

In spite of its name, RMSF is found throughout North and South America. It is transmitted to humans by the bite of an infected tick species, which in the United States includes the American dog tick, the Rocky Mountain wood tick, and the brown dog tick. It can be severe and potentially fatal without treatment. The antibiotic of choice is a common medication called doxycycline.

I went ahead and admitted my patient to the hospital, mainly for pain control and supportive care. The other doctors weren't convinced of the diagnosis because initial antibody tests for the disease were negative, so the possibility remained of another serious brain infection. But all other tests failed to show anything else, and he responded quickly to treatment.

Two days later he was discharged, hale and hearty, headaches and rash completely resolved.

Six weeks later, I sent follow-up blood tests for Rocky Mountain spotted fever, so-called "convalescent titers." Because there is a delay in the body's production of antibodies in response to infection, sometimes the only way to confirm a diagnosis is by comparing tests taken during the acute illness with repeat testing six to eight weeks later.

Sure enough, my patient's RMSF antibodies were sky-high. Or should that be "Rocky Mountain high"?