What is the diagnosis and treatment for intermittent headaches, fatigue, dehydration, myalgias, and peeling palms?

Diagnosis: Rocky Mountain Spotted Fever (RMSF) Until Proven Otherwise

This 42-year-old male with 4 weeks of intermittent headaches, fatigue, myalgias, and peeling palms requires immediate empiric doxycycline treatment for presumed Rocky Mountain Spotted Fever, as delay in recognition and treatment is the most important factor associated with death from RMSF. 1

Critical Diagnostic Reasoning

Why RMSF is the Primary Concern

• The classic triad of fever, rash, and reported tick bite is rarely present when patients first seek care, making early diagnosis challenging 1
• Peeling palms in this context strongly suggests late-stage manifestations of rickettsial infection, as rash can appear late or be atypical, localized, faint, or evanescent 1
• The 4-week duration with intermittent symptoms fits the pattern of untreated or partially treated rickettsial disease 1
• Early empiric therapy is the best way to prevent RMSF progression and resultant morbidity and mortality 1

Key Clinical Features Present

• Headache (86% of R. parkeri cases, likely similar in RMSF) 1
• Myalgia (76% of rickettsial infections) 1
• Fatigue (consistent with rickettsial disease) 1
• Peeling palms (suggests prior rash/dermatologic involvement, potentially late-stage RMSF with skin necrosis) 1
• "Feeling dehydrated" may reflect systemic illness and vascular leak 1

Immediate Management Algorithm

Step 1: Start Treatment NOW - Do Not Wait for Confirmation

• Begin doxycycline 100 mg orally twice daily immediately 1
• Treatment delay beyond day 5 of illness dramatically increases mortality risk (0% mortality when treated days 1-2 vs 27-50% mortality when treated days 7-9) 1
• Even if diagnosis is uncertain, the risk-benefit strongly favors empiric treatment 1

Step 2: Obtain Diagnostic Studies (But Do Not Delay Treatment)

Laboratory evaluation:

• Complete blood count looking for thrombocytopenia (common in RMSF) 1
• Hepatic transaminases (elevations expected) 1
• Basic metabolic panel to assess electrolytes and renal function 1
• Acute and convalescent serologies for rickettsial antibodies (will be negative early) 1

Imaging considerations:

• This patient does NOT require emergent neuroimaging unless focal neurological deficits develop 2, 3
• The 4-week duration and lack of "red flags" (sudden onset, neurological deficits, age >50, worsening with Valsalva) make secondary intracranial pathology less likely 2, 3, 4

Step 3: Assess for Complications

Examine carefully for:

• Rash on trunk, extremities, palms, and soles (may be faint or absent) 1
• Neurological deficits suggesting CNS involvement 1
• Signs of end-organ damage (renal, hepatic, pulmonary) 1
• Evidence of gangrene or skin necrosis (late-stage complication) 1

Alternative Diagnoses to Consider (But Treat RMSF First)

If Rickettsial Disease is Ruled Out

Other tickborne illnesses:

• Ehrlichiosis or anaplasmosis (similar presentation but typically less severe) 1
• These also respond to doxycycline, so empiric treatment covers both 1

Primary headache disorders:

• Chronic migraine requires ≥15 headache days per month for >3 months with ≥8 days meeting migraine criteria 1
• This patient's constellation of systemic symptoms (myalgias, peeling palms, dehydration) makes primary headache unlikely 1
• Migraine would not explain the dermatologic findings 1

Other considerations only if rickettsial disease excluded:

• Viral syndrome with post-viral fatigue
• Autoimmune/rheumatologic condition (given myalgias) 1
• Medication overuse headache (requires history of frequent analgesic use) 4

Critical Pitfalls to Avoid

1. Do not wait for rash to appear - it may never develop or may be too subtle to detect 1
2. Do not wait for tick bite history - most patients don't recall a bite 1
3. Do not wait for serologic confirmation - antibodies are typically negative in the first week 1
4. Do not assume "just a headache" - the systemic symptoms and dermatologic findings demand infectious workup 1
5. Do not order extensive neuroimaging before treating - this delays life-saving therapy 1

Follow-Up Plan

• Clinical improvement should occur within 24-48 hours of starting doxycycline 1
• Complete 7-10 days of doxycycline therapy 1
• If no improvement in 48-72 hours, reconsider diagnosis and obtain infectious disease consultation 1
• Convalescent serology at 2-4 weeks to confirm diagnosis retrospectively 1

If rickettsial disease is definitively excluded and symptoms persist, then consider referral to neurology for chronic headache evaluation 1, 4, but the peeling palms and systemic symptoms make this a secondary consideration only after infectious causes are ruled out.