Rocky Mountain spotted fever physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


There are several aspects of Rocky Mountain spotted fever (RMSF) that make it challenging for healthcare providers to diagnose and treat. The symptoms of RMSF vary from patient to patient and can easily resemble other, more common diseases. Treatment for this disease is most effective at preventing death if started in the first five days of symptoms. Diagnostic tests for this disease, especially tests based on the detection of antibodies, will frequently appear negative in the first 7-10 days of illness. Due to the complexities of this disease and the limitations of currently available diagnostic tests, there is no test available at this time that can provide a conclusive result in time to make important decisions about treatment.For this reason healthcare providers must use their judgment to treat patients based on clinical suspicion alone. Healthcare providers may find important information in the patient’s history and physical examination that may aid clinical suspicion. Information such as recent tick bites, exposure to high grass and tick-infested areas, contact with dogs, similar illnesses in family members or pets, or history of recent travel to areas of high incidence can be helpful in making the diagnosis.

Physical Examination

The diagnosis of RMSF must be made based on clinical signs and symptoms, and can later be confirmed using specialized confirmatory laboratory tests. Treatment should never be delayed pending the receipt of laboratory test results, or be withheld on the basis of an initial negative finding for R. rickettsii.

Initial physical signs may include:

  • Fever
  • Muscular tenderness
  • Anorexia [1]

Later signs and symptoms include:

  • Maculopapular rash
  • Petechial rash
  • Abdominal tenderness
  • Joint pain [1]


  • Patients with RMSF (90%) have some type of rash during the course of illness
  • Rash may not appear until after early onset symptoms, however treatment should start upon suspicion.
  • A classic case of RMSF involves a rash that first appears 2-5 days after the onset of fever
  • Rash appears as small, flat, pink, non-itchy spots (macules) on the wrists, forearms, and ankles and spreads to include the trunk and sometimes the palms and soles.
  • Often the rash varies from this description and people who fail to develop a rash, or develop an atypical rash, are at increased risk of being misdiagnosed.
  • The red to purple, spotted (petechial) rash of RMSF is usually not seen until the sixth day or later after onset of symptoms and occurs in 35-60% of patients with the infection.
  • A transition of red to purple coloration indicates a progression to severe disease, and every attempt should be made to begin treatment before petechiae develop.
  • It is important for physicians to consider RMSF if other signs and symptoms support a diagnosis, even if a rash is not present.



  1. 1.0 1.1 Rocky Mountain Spotted Fever Symptoms. Centers for Disease Control and Prevention (2015). Accessed on December 30, 2015