Mediterranean spotted fever: Presentation with pancytopenia

Mediterranean spotted fever (MSF), Boutonneuse fever, is a tick-borne disease caused by Rickettsia conorii and is endemic in the Mediterranean region. Although MSF is usually a benign infectious disease, unusual manifestations that have been mainly reported in severe forms, typically among elderly patients or those with underlying diseases, complicate the diagnosis. A 39-year-old woman, a resident of Bursa, Turkey, was admitted with a 5-day history of fever, headache, and malaise and a 3-day history of rash. Physical examination showed fever and maculopapular rash involving the trunk, extremities, palms, and soles. Hematological findings were as follows: Hb 10.8 g/dL, WBC 1.7  109/L with 62% polymorphonuclear cells; 9% bands; 20% lymphocytes; 6% metamyelocytes; 3% myelocytes;and platelet count 46.8  109/L. Laboratory studies revealed an elevated CRP (13 mg/L), accelerated ESR (60 mm/h), hypoalbuminemia (2.5 mg/L),and slightly elevated serum aspartate aminotransferase (53 UI/L) and lactate dehydrogenase (386 UI/L). Bone marrow smear showed hypercellular marrow with activation of myeloid cells. After 3 days of hospitalization, we learned that she has a dog in her yard. A ‘‘tache noire,’’ the typicaleschar at the site of the tick bite, was observed on the right inguinal region with more elaborate physical examination. Treatment with doxycycline (200mg/day) was started. Resolution of fever and normalization of haematological findings were observed on the 4th and the 6th days of treatment, respectively.