Introduction Israeli spotted fever (ISF) is caused by Rickettsia conorii Israeli spotted fever strain. In Portugal, it was first described in 1999.

Case report A twelve year old adolescent girl was admitted during summer with fever, macular rash (including palms and plants), mild headache, vomits and intense myalgia for three days. She had daily contact with dogs and lived in a rural area in the south of Portugal, but had no history of tick bites or eschar. Within 12 h she was in septic shock with multiorgan dysfunction (hypotension, obnubilation, leukopenia, thrombocytopenia, coagulopathy, respiratory distress, acute renal failure, hepatic dysfunction, hyperbilirubinemia and polyserositis) and was transferred to the intensive unit care. Empirical treatment with doxycicline, ceftriaxone, flucloxacillin and clyndamicyn was initiated. Rickettsial infection was confirmed by serology (over fourfold title increase by indirect immunofluorescence, four weeks after the acute illness – IgM >1024; IgG >4096) and by PCR. Sequencing confirmed the infection caused by R. conorii Israeli spotted fever strain. The adolescent evolved favourably with no sequelae.

Discussion Severe cases of Israeli spotted fever have been increasingly reported, mostly in adults. In children, it is usually a mild disease. The mechanism by which ISF strain causes more severe illness remains to be determined. The patient’s epidemiology and typical rash facilitated the early clinical diagnosis and prompt empirical treatment, which was probably crucial. The absence of an inoculation eschar should not delay the diagnosis.