An 18-month-old girl consulted for a tick bite on the head detected 24 hours earlier. The mother thinks it may have happened 3-4 days earlier, as they went on an outing to the countryside (April). There were no domestic animals (dogs or other pets) living with them. The tick was removed manually, and was about 5 mm in diameter. On the day of the consultation, he started a fever and was noted to have some lumps on his head.
On examination, she was in good general condition, although she was irritable and a little droopy. On the left parietoccipital region there was a blackish scar about 7 mm in diameter with mild erythema. On the skull there were multiple small mastoid and posterior cervical lymphadenopathies between 1 and 1.5 cm in diameter, slightly painful on palpation. The rest of the examination was normal and there were no rashes.
Initially, a blood test was requested to study the tick bite and treatment with amoxicillin-clavulanic acid was recommended in case of a possible superinfection of the bite.
One week later, the eschar, lymphadenopathy and fever persisted, the results of the tests showed leukocytosis with an increase in erythrocyte sedimentation rate (ESR) up to 20 mm/h and C-reactive protein (CRP) of 10 mg/dl, serology for Borrelia burgdorferri and Rickettesia connori were negative. In view of the poor evolution of the symptoms and suspicion of rickettsiosis, the case was consulted with the infectious disease specialists at our referral hospital and treatment with oral ciprofloxacin was decided, and a new blood test with serology was requested.
The patient was seen a week later, was afebrile and the lymphadenopathies were well tolerated and were slowly returning, with only a small area of alopecia of about 2 cm in diameter persisting. The control blood test showed a decrease in leukocytosis and SV.
The second serological control ten days later showed a titre of R. connori: IgG ≤ 1:40 and IgM 1:320.
At two months the child was asymptomatic and serology showed declining titres for R. connori IgG 1:40 and IgM ≤ 1:40.

