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A pilgrim’s progress: severe Rickettsia conorii infection complicated by gangrene

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This challenging case of acute febrile illness and rapidly evolving petechial rash and digital gangrene in a traveller who returned from North India and highlights the need for a high index of suspicion for rickettsial infection in returned travellers.

Clinical record

A 47-year-old Australian man of Vietnamese origin presented to hospital 3 days after returning from a 2-week pilgrimage to and in January 2012 with a 10-day history of fever and myalgia. He had developed high-grade fever with chills and rigors associated with myalgia 7 days after arriving in . Two days later, he developed nausea and vomiting. He had been vaccinated for hepatitis B and cholera before travel. He was not taking prophylactic antibiotics. He travelled with a group of 10 others who remained well. He recalled receiving a few mosquito bites, and noted rodent infestation and stray dogs in some of the temples he visited. A doctor in the group treated him empirically with oseltamivir after his initial symptoms began. A rash developed 2 days before his admission and 9 days after the onset of symptoms.

The main findings of an examination on admission were a high fever (40°C), a macular erythematous rash over his trunk and extremities sparing his palms and soles, and facial flushing. There were no eschars.

Laboratory investigations on admission showed a platelet count of 44 × 109/L (reference…