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PubMed This is a summary of 20 peer-reviewed journal articles Updated
Infectious Disease

Orientation and Understanding: Boutonneuse Fever

At a Glance

Boutonneuse fever, or Mediterranean spotted fever, is a highly treatable tick-borne bacterial infection. It is caused by a brown dog tick bite. Symptoms include a black-crusted sore at the bite site, fever, and rash, which are effectively cured with targeted antibiotics like doxycycline.

Boutonneuse fever, also known as Mediterranean spotted fever (MSF), is a treatable bacterial infection. It belongs to a group of illnesses called spotted fevers, which are caused by specialized bacteria that live inside host cells [1]. While the name suggests it is limited to the Mediterranean, it is also found in parts of Africa and the Middle East [2][3]. Understanding the biology of this infection can help you navigate your recovery with confidence.

Three Stabilizing Facts

If you have been diagnosed with or suspected of having Boutonneuse fever, keep these three points in mind:

  1. It is highly treatable: This condition is typically manageable and curable, especially when identified early [1][4].
  2. Antibiotics are effective: Targeted antibiotic therapy, most commonly with doxycycline, is highly effective at clearing the infection and preventing complications [5][6].
  3. Complete recovery is the standard: For most people with a healthy immune system, the course of the illness is predictable, and a full recovery is expected following proper treatment [7][8].

The Cause: Rickettsia conorii

The infection is caused by a bacterium called Rickettsia conorii [3]. Unlike many common bacteria that can grow anywhere, R. conorii must live inside the cells of its host to survive and reproduce [1]. There are several subspecies of this bacterium, such as R. conorii subsp. israelensis, which may be found in different geographic locations [9].

How It Spreads: The Brown Dog Tick

Boutonneuse fever is not spread from person to person. Instead, it is a zoonotic disease, meaning it jumps from animals to humans via an insect [10].

  • The Vector: The primary carrier is the brown dog tick (Rhipicephalus sanguineus) [11].
  • The Cycle: These ticks often live in close proximity to humans and domestic dogs. The infection is transmitted when an infected tick bites a human host [10][12].
  • Seasonality: You are most likely to encounter these ticks during the summer and autumn months when they are most active [13][14].

Biology of the Infection

When an infected tick bites, the R. conorii bacteria enter the skin and begin to spread.

  • The Tache Noire: At the site of the bite, a small, painless ulcer with a black crust often forms. This is called a tache noire (French for “black stain”) or an eschar [15]. This represents the initial area where the immune system is reacting to the bacteria [1].
  • Targeting the Blood Vessels: Once inside the body, the bacteria specifically target endothelial cells, which are the cells that line your blood vessels [1].
  • Vasculitis: As the bacteria invade and multiply within these cells, they cause vasculitis, or inflammation of the blood vessels [15]. This inflammation is what leads to the characteristic rash and other symptoms associated with the fever.

Geography and Risk

While Boutonneuse fever is most famous in the Mediterranean basin (including countries like Tunisia, Romania, and Jordan), its reach is expanding [16][17]. Changing climates are allowing the brown dog tick to thrive in new areas, leading to cases in regions previously thought to be unaffected [18]. Regardless of the location, the primary risk factor remains exposure to tick-infested environments, particularly those shared with dogs [19][20].

Common questions in this guide

Is Boutonneuse fever curable?
Yes, Boutonneuse fever is highly treatable and usually curable. A full recovery is the standard outcome for most people when the infection is identified early and treated with targeted antibiotics like doxycycline.
How do you get Mediterranean spotted fever?
It is spread to humans through the bite of an infected brown dog tick. It is a zoonotic disease, meaning it jumps from animals to humans via insects, and cannot be spread directly from person to person.
What is a tache noire?
A tache noire is a small, painless sore with a black crust that forms at the site of the tick bite. It is the initial spot where your immune system reacts to the bacteria and is a key physical sign doctors look for during diagnosis.
What are the symptoms of Boutonneuse fever?
Common signs include a fever, a distinct black-crusted sore called an eschar or tache noire at the tick bite site, and a rash that often appears on the body, including the palms of your hands and soles of your feet.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Am I a candidate for doxycycline, and how quickly should we start treatment?
  2. 2.Can you check my skin for a 'tache noire' or help me identify if this lesion is an eschar?
  3. 3.Based on my travel history or location, are there other Rickettsia subspecies common in this area that I should be aware of?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    Mediterranean Spotted Fever: Current Knowledge and Recent Advances.

    Spernovasilis N, Markaki I, Papadakis M, et al.

    Tropical medicine and infectious disease 2021; (6(4)) doi:10.3390/tropicalmed6040172.

    PMID: 34698275
  2. 2

    Mediterranean spotted fever with multiorgan involvement.

    Davis K, Ahmado A, Warrell CE, et al.

    BMJ case reports 2022; (15(12)) doi:10.1136/bcr-2022-249426.

    PMID: 36543366
  3. 3

    The case of Mediterranean spotted fever of the traveler returned from Zambia.

    Ichikawa T, Qiu Y, Ando S, et al.

    Ticks and tick-borne diseases 2024; (15(4)):102347 doi:10.1016/j.ttbdis.2024.102347.

    PMID: 38714072
  4. 4

    Challenges in Diagnosing Rickettsial Infection: A Case Report of Rickettsia conorii in a Pediatric Patient in Iran.

    Hosseininasab A, Latifian M, Jamallpour H, et al.

    The Pediatric infectious disease journal 2025; (44(8)):e305-e306 doi:10.1097/INF.0000000000004799.

    PMID: 40073389
  5. 5

    A Rare Case of Mediterranean Spotted Fever and Encephalitis.

    Sousa Almeida R, Pego PM, Pinto MJ, Matos Costa J

    Case reports in infectious diseases 2016; (2016()):2421540 doi:10.1155/2016/2421540.

    PMID: 28053795
  6. 6

    Doxycycline and Tooth Discoloration in Children: Changing of Recommendations Based on Evidence of Safety.

    Stultz JS, Eiland LS

    The Annals of pharmacotherapy 2019; (53(11)):1162-1166 doi:10.1177/1060028019863796.

    PMID: 31280586
  7. 7

    [Mediterranean Spotted Fever: Retrospective Review of Hospitalized Cases and Predictive Factors of Severe Disease].

    Meireles M, Magalhães R, Guimas A

    Acta medica portuguesa 2015; (28(5)):624-31.

    PMID: 26667867
  8. 8

    Spotted fever rickettsioses causing myocarditis and ARDS: a case from Sri Lanka.

    Herath HMLY, Jayasundara JMHD, Senadhira SDN, et al.

    BMC infectious diseases 2018; (18(1)):705 doi:10.1186/s12879-018-3631-6.

    PMID: 30594148
  9. 9

    Fatal Case of Mediterranean Spotted Fever Associated with Septic Shock, Iran.

    Esmaeili S, Latifian M, Khalili M, et al.

    Emerging infectious diseases 2022; (28(2)):485-488 doi:10.3201/eid2802.211023.

    PMID: 35076374
  10. 10

    Antibody Seroprevalence to Spotted Fever Group Rickettsiae in Miraflores, Colombia: A Cross-Sectional Study in Humans and Dogs.

    Gual-Gonzalez L, Cantillo-Barraza O, Torres ME, et al.

    The American journal of tropical medicine and hygiene 2024; (110(6)):1245-1252 doi:10.4269/ajtmh.23-0593.

    PMID: 38593790
  11. 11

    A Cross Sectional Study on Serological Prevalence of Ehrlichia canis and Rickettsia conorii in Different Canine Population of Sicily (South-Italy) during 2017-2019.

    Migliore S, Gargano V, De Maria C, et al.

    Animals : an open access journal from MDPI 2020; (10(12)) doi:10.3390/ani10122444.

    PMID: 33419379
  12. 12

    Seroepidemiology of Rickettsia conorii in dogs in Portugal: a comprehensive 12-year retrospective study (2013-2024).

    Lopes R, Lima de Carvalho H, Garcês A, et al.

    Parasites & vectors 2025; (18(1)):238 doi:10.1186/s13071-025-06859-z.

    PMID: 40551164
  13. 13

    Rickettsia conorii retinitis: an emerging infection in the southeast of the Iberian Peninsula.

    Pérez-Rueda A

    Archivos de la Sociedad Espanola de Oftalmologia 2020; (95(10)):507-511 doi:10.1016/j.oftal.2020.05.011.

    PMID: 32553798
  14. 14

    Molecular Identification of Spotted Fever Group Rickettsiae in Ticks in the Republic of Korea.

    Seo JY, Park JS, Lee HI, Ju JW

    Pathogens (Basel, Switzerland) 2024; (13(7)) doi:10.3390/pathogens13070575.

    PMID: 39057802
  15. 15

    Cases of Mediterranean spotted fever in southeast of Iran.

    Farrokhnia M, Ghalejoogh ZY, Rohani M, et al.

    Iranian journal of microbiology 2020; (12(3)):256-260.

    PMID: 32685123
  16. 16

    Molecular diagnosis of Rickettsia infection in patients from Tunisia.

    Khrouf F, Sellami H, Elleuch E, et al.

    Ticks and tick-borne diseases 2016; (7(5)):653-656 doi:10.1016/j.ttbdis.2016.02.010.

    PMID: 26897395
  17. 17

    Boutonneuse Fever in Southeastern Romania.

    Cambrea SC, Badiu D, Ionescu C, et al.

    Microorganisms 2023; (11(11)) doi:10.3390/microorganisms11112734.

    PMID: 38004746
  18. 18

    Identifying New Areas of Endemicity and Risk Factors for Rickettsia conorii subsp. conorii Infection: Serosurvey in Rural Areas of Romania.

    Cheran CA, Panciu AM, Riciu CD, et al.

    Pathogens (Basel, Switzerland) 2024; (13(9)) doi:10.3390/pathogens13090783.

    PMID: 39338974
  19. 19

    Epidemiological evaluation of Mediterranean spotted fever in children of the Karak province in south Jordan.

    Nafi O, Tarawnah Y, Tarawnah A

    Journal of infection in developing countries 2017; (11(3)):242-246 doi:10.3855/jidc.8154.

    PMID: 28368858
  20. 20

    First Evidence of Rickettsia conorii Infection in Dogs in Northern Tunisia.

    Gharbi Z, Ouni A, Balti G, et al.

    Veterinary sciences 2024; (11(9)) doi:10.3390/vetsci11090402.

    PMID: 39330781

This page provides educational information about Boutonneuse fever. Always consult an infectious disease specialist or primary care provider for a proper diagnosis and appropriate antibiotic treatment.

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