Hitch-hiker taken for a ride: an unusual cause of myocarditis, septic shock and adult respiratory distress syndrome

Abstract

Rocky Mountain spotted fever (RMSF) is a serious tick-borne illness caused by Rickettsia rickettsii that is endemic in southeastern USA. Although RMSF has been described as causing the classic clinical triad of fever, headache and a characteristic rash, serious and potentially life-threatening manifestations can occur. Cardiopulmonary involvement, although infrequent, may occur with severe cases of RMSF. Rickettsial myocarditis is an uncommon occurrence. We present a case of a previously healthy 26-year-old man, who was hitch-hiking across the southeastern USA, with serologically proven RMSF causing adult respiratory distress syndrome, septic shock and myocarditis manifested by elevated cardiac enzymes and decrease in myocardial function. After treatment with antibiotics, the myocarditis resolved. Therefore, although unusual, clinicians should be aware of possible myocardial involvement in patients with appropriate tick-exposure histories or other clinical signs of RMSF.

Figure 1

Chest radiograph on hospital day 1 after emergent intubation showing scattered bilateral infiltrates consistent with adult respiratory distress syndrome.

Figure 2

ECG on hospital day 4 indicating prolonged QT and non-specific ST abnormality. Ventricular rate of 95 beats/min. Cardiac conduction abnormalities have been described in cases of rickettsial myocarditis.

Figure 3

Characteristic maculopapular rash of Rocky Mountain spotted fever on the arm of the patient, hospital day 2.