Rickettsia conorii

A tickborne rickettsial species that causes boutonneuse fever, the most severe form of rickettsial spotted fever next to Rocky Mountain spotted fever
Also known as Marseilles fever, Mediterranean spotted fever, Kenya tick typhus, Israeli tick typhus, Astrakhan spotted fever, and Indian tick typhus

Background

Transmitted by Rhipicephalus sanguineus ticks
Founds in India, Pakistan, Israel, Russia, Georgia, Bulgaria, Turkey, Ukraine, Ethiopia, Kenya, South Africa, Morocco, and southern Europe
More cases occur during the warm months (July through September in the Mediterranean)

Incubation period of 7 days
Initial symptoms include fever, myalgias, and headache
Often has an eschar at the site of tick bit inoculation ("tache noir"), but not always
Petechial rash, GI symptoms, obtundation, tachypnea, hepatomegaly, leukocytosis, coagulopathy, AKI, bilirubin elevation, AST elevation, and CK elevation
Procoagulant, and 10% develop DVT
Can present as acute pancreatitis
Can be quite severe with higher mortality than others in the spotted fever group

First-line: doxycycline 100 mg po bid for 7 days (at least 5-7 days and resolution of symptoms for 3 days)
- May be able to shorten to a single day of two doses of 200 mg each in one small study
- Could use minocycline
Ciprofloxacin is associated with a more severe course and should be avoided
Azithromycin or clarithromycin may be considered in pregnant women or children