The disease progresses to hypotensive shock within 48 hours, and the patient develops a diffuse, macular, erythematous rash with non-purulent conjunctivitis. Urine output is often decreased, and patients may be disoriented or combative. The adult respiratory distress syndrome or cardiac dysfunction may also be seen. Laboratory studies reveal elevated blood urea nitrogen, serum creatinine, bilirubin, and creatine phosphokinase levels, and white blood cell counts with marked left shifts. Platelet counts are low in the first week of illness but are usually high in the second week.
Patients require large volumes of fluid to maintain perfusion and usually require intensive care.
In the recovery phase, there is desquamation of at least the palms, soles, or digits and often of other skin areas as well. The mean age is 24.8 years, with a range of 13-52 years. Two others had onset of illness 10 days after onset of menses. No evidence for leptospirosis, Rocky Mountain spotted fever, viral exanthematous diseases, or streptococcal scarlet fever has been found in those patients in whom it has been looked for. This ratio is probably high because severe cases are easier to recognize.