RMSF is a tick-borne disease which is the most common Rickettsial infection in the United States. It has multiple organ system involvements which can make diagnosis difficult.

To describe a case of biopsy-proven Rocky Mountain Spotted Fever (RMSF) with both central and peripheral nervous system manifestations.

Not applicable

A 68 year old, female patient presented with gastrointestinal symptoms initially thought to be a diverticulitis flare. She then developed multiple metabolic abnormalities including leukocytosis, hyponatremia, and hypokalemia as well as lipase elevation. Over the next few days she became progressively encephalopathic to the point of not speaking and developed diffuse weakness (all limbs as well as difficulty swallowing); she ended up requiring intubation for airway protection. She received empiric 5-day course of IV immunoglobulins due to concern for Guillain-Barre like illness. Electromyogram/nerve conduction study (EMG/NCS) demonstrated an axonal neuropathy and MRI of the brain showed innumerable punctate subacute infarcts within the bilateral cerebral white matter as well as the right cerebellum.

A petechial rash had been noted earlier in hospital course and skin biopsy was found to be consistent with RMFS. She was started on doxycycline with improvement in mental status and weakness but required acute rehabilitation after hospital discharge. She was seen in neurology clinic 3 months after hospital discharge and she had returned to her cognitive and physical baseline. Repeat EMG/NCS approximately 5 months after hospital admission showed resolution of the axonal neuropathy.

RMSF is a tick-borne Rickettsial illness which requires a high index of suspicion for diagnosis. This case represents both central and peripheral nervous system involvement from RMSF. The microvessel cerebral vasculitis causing a ‘Starry sky’ appearance on MRI brain has been reported before. Acute peripheral neuropathy has rarely previously been reported.