I read with interest the article on Rocky Mountain spotted fever (RMSF) by Masters et al1 that recently appeared in the ARCHIVES. The authors emphasized pitfalls in the diagnosis and treatment of RMSF, which are important for clinicians. As a review article, I believe several important clinical points were omitted.
The 2 cases presented in the article were not those of the authors and were of young children initially diagnosed as having a "viral syndrome." It is hard to understand how these cases could have been dismissed as viral. There are virtually no other infectious diseases that present initially with macules on the wrists and/or ankles and also involve the palms and/or soles. Enteroviral diseases of summer do not have the same distribution. Similarly, the mild increase in serum transaminases should have been another clue that the patients simply did not have a "viral syndrome," particularly when it occurs in summer in a febrile patient with a macular rash on the wrists and/or soles. Dismissing these patients as having viral gastroenteritis simply because they had diarrhea is also another pitfall. Excluding RMSF, no infection presenting with diarrhea is accompanied by a mild increase in serum transaminases, and the characteristic wrist and/or ankle rash of RMSF.
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