It is petechial and purpuric which begins on the trunk and spreads to the extremities and soles. Diagnosis is once again from history and epidemiologic awareness. Can be seen in elderly or chronically ill. Gradual onset with malaise and fatigue with eventual fever. Hemolysis, thrombocytopenia, and liver dysfunction can be seen on labs.
Peripheral smear shows intraerythrocitic ring forms.
Usually there is an embedded tick that has been present for several days.