Medication Summary

A brief course of a tetracycline antibiotic is recommended. Quinolones may also be considered. Chloramphenicol is an alternate treatment but is not usually recommended because of substantial toxicity.

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy)

View full drug information

Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Follow-up

Szabó MP, Pinter A, Labruna MB. Ecology, biology and distribution of spotted-fever tick vectors in Brazil. Front Cell Infect Microbiol. 2013. 3:27. [QxMD MEDLINE Link]. [Full Text].
Weinert LA, Werren JH, Aebi A, Stone GN, Jiggins FM. Evolution and diversity of Rickettsia bacteria. BMC Biol. 2009 Feb 2. 7:6. [QxMD MEDLINE Link]. [Full Text].
Akram SM, Jamil RT, Gossman WG. Rickettsia Akari (Rickettsialpox). 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Huebner RJ, Stamps P, Armstrong C. Rickettsialpox. A newly recognized rickettsial disease. 1. isolation of the etiological agent. Public Health Report. 1946. 61:1605.
Parola P. Rickettsia felis: from a rare disease in the USA to a common cause of fever in sub-Saharan Africa. Clin Microbiol Infect. 2011 Jul. 17(7):996-1000. [QxMD MEDLINE Link].
Schulze TL, Jordan RA, White JC, Roegner VE, Healy SP. Geographical distribution and prevalence of selected Borrelia, Ehrlichia, and Rickettsia infections in Amblyomma americanum (Acari: Ixodidae) in New Jersey. J Am Mosq Control Assoc. 2011 Sep. 27(3):236-44. [QxMD MEDLINE Link].
Breitschwerdt EB, Hegarty BC, Maggi RG, Lantos PM, Aslett DM, Bradley JM. Rickettsia rickettsii transmission by a lone star tick, North Carolina. Emerg Infect Dis. 2011 May. 17(5):873-5. [QxMD MEDLINE Link].
Bennett SG, Comer JA, Smith HM, Webb JP. Serologic evidence of a Rickettsia akari-like infection among wild-caught rodents in Orange County and humans in Los Angeles County, California. J Vector Ecol. 2007 Dec. 32 (2):198-201. [QxMD MEDLINE Link].
Comer JA, Tzianabos T, Flynn C, Vlahov D, Childs JE. Serologic evidence of rickettsialpox (Rickettsia akari) infection among intravenous drug users in inner-city Baltimore, Maryland. Am J Trop Med Hyg. 1999 Jun. 60(6):894-8. [QxMD MEDLINE Link].
Comer JA, Diaz T, Vlahov D, Monterroso E, Childs JE. Evidence of rodent-associated Bartonella and Rickettsia infections among intravenous drug users from Central and East Harlem, New York City. Am J Trop Med Hyg. 2001 Dec. 65(6):855-60. [QxMD MEDLINE Link].
Paddock CD, Zaki SR, Koss T, Singleton J Jr, Sumner JW, Comer JA, et al. Rickettsialpox in New York City: a persistent urban zoonosis. Ann N Y Acad Sci. 2003 Jun. 990:36-44. [QxMD MEDLINE Link].
Rickettsialpox. City of New York Health. Available at https://www1.nyc.gov/site/doh/health/health-topics/rickettsialpox.page. Accessed: June 25, 2017.
Bailey MS, Trinick TR, Dunbar JA, Hatch R, Osborne JC, Brooks TJ, et al. Undifferentiated febrile illnesses amongst British troops in Helmand, Afghanistan. J R Army Med Corps. 2011 Jun. 157(2):150-5. [QxMD MEDLINE Link].
Bolaños-Rivero M, Santana-Rodriguez E, Angel-Moreno A, Hernández-Cabrera M, Limiñana-Canal JM, Carranza-Rodríguez C, et al. Seroprevalence of Rickettsia typhi and Rickettsia conorii infections in the Canary Islands (Spain). Int J Infect Dis. 2011 Jul. 15(7):e481-5. [QxMD MEDLINE Link].
Renvoisé A, van't Wout JW, van der Schroeff JG, Beersma MF, Raoult D. A case of rickettsialpox in Northern Europe. Int J Infect Dis. 2012 Mar. 16 (3):e221-2. [QxMD MEDLINE Link].
Paddock CD, Eremeeva ME. Raoult D, Parola P. Rickettsial diseases. New York: Informa Healthcare; 2007. 63-86.
Sekeyová Z, Danchenko M, Filipčík P, Fournier PE. Rickettsial infections of the central nervous system. PLoS Negl Trop Dis. 2019 Aug. 13 (8):e0007469. [QxMD MEDLINE Link].
Jeong MA, Youn SK, Kim YK, Lee H, Kim SJ, Sohn A. Trends in the incidence of scrub typhus: the fastest growing vector-borne disease in Korea. Osong Public Health Res Perspect. 2013 Jun. 4(3):166-9. [QxMD MEDLINE Link]. [Full Text].
Chung JH, Yun NR, Kim DM, Lee JW, Yoon SH, Kim SW. Scrub typhus and cerebrovascular injury: a phenomenon of delayed treatment?. Am J Trop Med Hyg. 2013 Jul. 89(1):119-22. [QxMD MEDLINE Link]. [Full Text].
Hananiya A, Douglas LC, Fagan M. Rickettsialpox in a Pediatric Patient. Pediatr Emerg Care. 2017 Apr. 33 (4):260-262. [QxMD MEDLINE Link].
Portillo A, de Sousa R, Santibáñez S, Duarte A, Edouard S, Fonseca IP, et al. Guidelines for the Detection of Rickettsia spp. Vector Borne Zoonotic Dis. 2017 Jan. 17 (1):23-32. [QxMD MEDLINE Link].
Trout Fryxell RT, Steelman CD, Szalanski AL, Billingsley PM, Williamson PC. Molecular Detection of Rickettsia Species Within Ticks (Acari: Ixodidae) Collected from Arkansas United States. J Med Entomol. 2015 May. 52 (3):500-8. [QxMD MEDLINE Link].
Denison AM, Amin BD, Nicholson WL, Paddock CD. Detection of Rickettsia rickettsii, Rickettsia parkeri, and Rickettsia akari in skin biopsy specimens using a multiplex real-time polymerase chain reaction assay. Clin Infect Dis. 2014 Sep 1. 59 (5):635-42. [QxMD MEDLINE Link].
Vyas NS, Shieh WJ, Phelps RG. Investigating the histopathological findings and immunolocalization of rickettsialpox infection in skin biopsies: A case series and review of the literature. J Cutan Pathol. 2020 Jan 18. [QxMD MEDLINE Link].
Kass EM, Szaniawski WK, Levy H, Leach J, Srinivasan K, Rives C. Rickettsialpox in a New York City hospital, 1980 to 1989. N Engl J Med. 1994 Dec 15. 331(24):1612-7. [QxMD MEDLINE Link].
Krusell A, Comer JA, Sexton DJ. Rickettsialpox in North Carolina: a case report. Emerg Infect Dis. 2002 Jul. 8(7):727-8. [QxMD MEDLINE Link].
McDade JE, Black CM, Roumillat LF, Redus MA, Spruill CL. Addition of monoclonal antibodies specific for Rickettsia akari to the rickettsial diagnostic panel. J Clin Microbiol. 1988 Oct. 26(10):2221-3. [QxMD MEDLINE Link].
Ozturk MK, Gunes T, Kose M, Coker C, Radulovic S. Rickettsialpox in Turkey. Emerg Infect Dis. 2003 Nov. 9(11):1498-9. [QxMD MEDLINE Link].
Paddock CD, Koss T, Eremeeva ME, Dasch GA, Zaki SR, Sumner JW. Isolation of Rickettsia akari from eschars of patients with rickettsialpox. Am J Trop Med Hyg. 2006 Oct. 75(4):732-8. [QxMD MEDLINE Link].
Paddock CD, Sumner JW, Comer JA, Zaki SR, Goldsmith CS, Goddard J, et al. Rickettsia parkeri: a newly recognized cause of spotted fever rickettsiosis in the United States. Clin Infect Dis. 2004 Mar 15. 38(6):805-11. [QxMD MEDLINE Link].
Radulovic S, Feng HM, Morovic M, Djelalija B, Popov V, Crocquet-Valdes P, et al. Isolation of Rickettsia akari from a patient in a region where Mediterranean spotted fever is endemic. Clin Infect Dis. 1996 Feb. 22(2):216-20. [QxMD MEDLINE Link].
Saini R, Pui JC, Burgin S. Rickettsialpox: report of three cases and a review. J Am Acad Dermatol. 2004 Nov. 51(5 Suppl):S137-42. [QxMD MEDLINE Link].
Walker DH. Rickettsioses of the spotted fever group around the world. J Dermatol. 1989 Jun. 16(3):169-77. [QxMD MEDLINE Link].
Walker DH, Hudnall SD, Szaniawski WK, Feng HM. Monoclonal antibody-based immunohistochemical diagnosis of rickettsialpox: the macrophage is the principal target. Mod Pathol. 1999 May. 12(5):529-33. [QxMD MEDLINE Link].
Diop A, El Karkouri K, Raoult D, Fournier PE. Genome sequence-based criteria for demarcation and definition of species in the genus Rickettsia. Int J Syst Evol Microbiol. 2020 Jan 14. [QxMD MEDLINE Link].

Media Gallery

Multiple papulovesicles involving the upper trunk on a patient with rickettsialpox in North Carolina. Courtesy of the CDC.
Global distribution of confirmed cases of rickettsialpox.
Rickettsialpox eschar on posterior right calf of patient from North Carolina. Courtesy of the CDC.

of 3

Table 1. Characteristics of Similar Conditions

Table 1. Characteristics of Similar Conditions

Disease	Rash/Eschar	Generalized Rash	Clinical Features	Geography
Rickettsialpox secondary to R akari infection	A red papule with a vesicle in the center dries and forms a black eschar with surrounding induration. Multiple eschars are possible.	The papulovesicular rash is usually on the trunk and extremities; the palms, soles, and oral mucosa may also be involved.	The papule precedes the febrile illness and mild systemic symptoms. Regional lymphadenopathy may develop.	See Frequency
Chickenpox secondary to varicella zoster infection	The papule turns into a vesicle on an erythematous base and resembles a "dew drop on a rose petal."	The rash begins on the head and progresses to the trunk, arms, and then legs; vesicles are present in all stages.	It is common in children. No black eschar is present.	Worldwide
Mediterranean spotted fever secondary to Rickettsia conorii infection	At the site of a tick bite, a single eschar with a red halo forms.	The rash is generalized, involves the palms and soles, and is often maculopapular, occasionally petechial.	Fever, headache, myalgias may develop. The onset is abrupt. The disease may be severe in context of comorbidity.	North Africa, Middle East, Southern Europe
African tick bite fever secondary to R africae infection	Single or multiple eschars with regional lymphadenopathy	A scant generalized rash, vesicular or maculopapular, may be present. Conversely, the rash may be absent.	Fever, headache, myalgias, regional lymphadenopathy; associated with reports of subacute neuropathy	Sub-Saharan Africa, Caribbean
Human spotted fever secondary to R parkeri infection	Single or multiple eschars develop from erythematous papules.	Scant nonpruritic papules	Fever, headache, myalgias, arthralgias	United States
Scrub typhus secondary to Orientia tsutsugamushi infection	A vesicle or black scab appears on an erythematous base at the bite site.	Vesicles are usually on the trunk or extremities.	The rash fades within a few days; pneumonitis is common.	Asia-Pacific rim

Back to List

Author

Darvin Scott Smith, MD, MSc, DTM&H Adjunct Associate Clinical Professor, Department of Microbiology and Immunology, Stanford University School of Medicine; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Permanente Medical Group

Darvin Scott Smith, MD, MSc, DTM&H is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Evelyn Zhang, BS MD Candidate, Icahn School of Medicine at Mount Sinai

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine in New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use of Antibiotics, Alpha Omega Alpha, American Association for Physician Leadership, American Association for the Advancement of Science, American Association of University Professors, American Clinical and Climatological Association, American College of Physicians, American Federation for Medical Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges, Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society for Obstetrics and Gynecology, Infectious Diseases Society of America, Louisiana State Medical Society, Orleans Parish Medical Society, Royal Society of Medicine, Sigma Xi, The Scientific Research Honor Society, Society of General Internal Medicine, Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, Southwestern Association of Clinical Microbiology, The Foundation for AIDS Research

Disclosure: Receives royalties from Baxter International for: Takeda-receives royalties; UpToDate-receives royalties.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Fred A Lopez, MD Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, Louisiana State Medical Society

Disclosure: Nothing to disclose.

Chi Hiong U Go, MD Assistant Professor, Department of Internal Medicine, Texas Tech University Health Science Center at Odessa

Chi Hiong U Go, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine

Disclosure: Nothing to disclose.

Julie A Ake, MD Fellow, Infectious Disease Service, Walter Reed Army Medical Center

Disclosure: Nothing to disclose.

Timothy J Whitman, DO Consulting Staff, Department of Infectious Disease, National Naval Medical Center

Disclosure: Nothing to disclose.

Mohammad J Alam, MD Assistant Professor of Medicine, Departments of Internal Medicine, Infectious Disease, and Emergency Medicine, University Health, Louisiana State University School of Medicine in Shreveport; Affiliate Staff Physician, Department of Internal Medicine (Infectious Disease), Schumpert Medical Center

Mohammad J Alam, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Society of Critical Care Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

Pradeep Kumar Mada, MD, MRCP(UK) Consulting Physician in Infectious Diseases, Comanche County Memorial Hospital

Disclosure: Nothing to disclose.