BACKGROUND
Tick-borne infections are underrecognized causes of acute febrile illness in the Middle East, including rickettsial spotted fever and tick-borne relapsing fever. Rickettsial fever commonly presents with fever, headache, and an eschar, while relapsing fever is characterized by recurrent fever episodes. Despite documented cases in Saudi Arabia and Middle Eastern countries, these infections remain underdiagnosed due to nonspecific presentations, limited diagnostic capacity, and low clinical suspicion.
CASE REPORT
A 55-year-old Saudi man presented to the emergency department of King Abdulaziz Medical City, Riyadh, with a history of 2 weeks of intermittent fever and a recently noticed rash. His past medical history included diabetes mellitus type 2 and depression. He was an active smoker with no known drug allergies. He reported intermittent fever and rash following a reported tick bite on the left great toe 2 weeks earlier while he was visiting his camels in a rural area. Examination revealed an erythematous nodule with a central necrotic eschar on the toe and a generalized maculopapular rash. Laboratory investigations were unremarkable except for mildly elevated inflammatory markers. Serologic tests for common viral and bacterial febrile illnesses were negative. Given the suspicion of rickettsial or relapsing fever, we initiated empirical doxycycline and ciprofloxacin. Following significant clinical improvement, he was discharged on doxycycline.
CONCLUSIONS
This case highlights the need to consider tick-borne febrile illness in patients with compatible exposure history, rash, and eschar-like lesions. It also illustrates the diagnostic challenges that arise when confirmatory testing is unavailable. Empiric doxycycline may be appropriate when the clinical presentation is compatible and testing is limited.

Keywords: Case Reports; Doxycycline; Relapsing Fever; Rickettsia Infections; Saudi Arabia; Tick-Borne Diseases