Delayed fatal diagnosis in atypical rickettsial infectious disease

We report the case of an 84-year-old man admitted to ICU with symptoms/signs occurring after upper respiratory airways disease. The upper respiratory condition consisting in an uvula oedema required an empiric anti-inflammatory and antibiotic therapy which masked the clinical features usually seen in the case of rickettsial infections, especially cutaneous rash. Although the patient subsequently presented unexplained cardiac and neurological involvement, the starting treatment interfered with the diagnostic process, resulting in a delayed diagnosis. Rickettsia and other conditions related with a possible tick bite have to be considered in the list of differential diagnosis especially in the case of severe systemic or localised disease, particularly when the only suspicious sign is a clinical history indicative of a patient living in poor conditions of hygiene.