[2018] Jessi Herr (SU18 NSG 346 Patho): Rocky Mountain Spotted Fever

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[2018] Jessi Herr (SU18 NSG 346 Patho): Rocky Mountain Spotted Fever

Epidemiology • Distributed across Western Hemisphere (Parola et al., 2013).• Infection rate is highest when ticks are active, April-September (Biggs et al., 2016). • Most common in Midwest and Southeast • Number of cases has increased dramatically • 4,470 cases in 2012 (Biggs et al., 2016) • Some Native American communities  have very high infection        rates due to feral dogs.• Infection and mortality rates 4X higher for these Native                  American populations (Parola et al. 2013).

Rocky Mountain Spotted Fever (RMSF)

Diagnosis• Presents with a wide-spread rash that starts on the wrists and ankles and moves toward the trunk. 10 % of patients have no rash. Initial rash is small, red, non-itchy and macular; progresses to itchy maculopapular, petichial or purpuric lesions (Faccini-Martinez, Garcia-Alvarez, Hidalgo, & oteo, 2014).• Lab diagnosis is based on PCR, qPCR, IgG or IgM indirect immunofluorescence assay• Culturing is definitive but is rarely done due to biohazard concerns (Faccini-Martinez et al., 2014).

RMSF incidence rate per million people in 2014 (CDC)

Check for ticks after being outside!

Signs and Symptoms

Edema around the eyes/back of hands

Myalgia(muscle pain)

Abdominal Pain


Non-itchy rash with small red/purple dotsstarting on the wristsand progressing to the core

Late Stage: Digital necrosis

Pathophysiology• Bacterial infection caused by Rickettsia rickettsii, an intracellular parasite that invades via a receptor-mediated mechanism and multiplies in the cytoplasm or nuclei of endothelial cells lining arterioles and venules (Sahni, Narra, Sahni, & Walker, 2013) • Causes vasculitis and increased vascular permeability resulting in blood leakage into adjacent tissues and the non-itchy, red dotted, rash• As infection progresses inflammation processes lead to coagulation and the production of thrombosis and thrombocytopenia • Plasma loss leads to increased interstitial fluid volume and edema (Sahni et al., 2013).

Late Stage: Cerebral and Pulmonaryedema



Complications  • Encephalitis• Inflammation of the heart or lungs.• Kidney failure. • Amputation due to digital necrosis• Death: untreated, RMSF has had a           mortality rate as high as 80 percent (Mayo     Clinic, 2011).

Treatment • Doxycycline is recommended for all patients unless they have an allergy, or are pregnant • Doctor may prescribe chloramphenicol as an alternative (Mayo Clinic, 2011)   • Patients receiving treatment more than 5 days after onset are 5 times more likely to die • Treatment is typically delayed due to absence of a rash which usually does not appear before day 3

What is it? Rocky Mountain spotted fever (RMSF) is a serious tick-borne illness which can be deadly if not treated early. It is spread by several species of ticks in the United States, resulting in symptoms of general inflammation, rash and eventually to digital necrosis and death if left untreated. RMSF cases occur throughout the United States, and can be diagnosed through laboratory testing and treated with Doxycycline. (Mayo Clinic,2011)

If an infected tick attaches to the skin, RMSF can be contracted when tick is removed, as fluid from the tick can enter the body through an opening such as the bite site (Mayo Clinic, 2011).

Nursing Considerations

Treatment is most effective if started within few days of symptoms.

Mortality is highest in patients 50 yo and above, children from 5 to 9 yo, and people with no recognized tick bite. Approximately half of pediatric cases have no recall of tick bite.

Prevention • There is no vaccine • Treat clothing and           gear with permethrin. • Use insect replellents  containing DEET,        picardin, IR3535, oil of lemon eucalyptus, para-menthane-diol, or 2-undecanone (Mayo Clinic, 2011).

A typical RMSF rash (CDC)

Pelle Rudstam, Elizabeth Nestler, Jessi Herr

(Mayo Clinic, 2011)