Patient: Female, 43-year-old Final Diagnosis: Rocky Mountain spotted fever Symptoms: Acute kidney injury • hyponatremia • rash Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Rare disease Background: Rocky Mountain spotted fever (RMSF) is a potentially fatal infectious disease caused by the gram-negative intracellular bacterium Rickettsia rickettsii . The classic triad includes fever, rash, and history of tick exposure; however, the triad presents in only 3% to 18% of cases at the initial visit, and the tick bite is often painless and overlooked. RMSF can present with other manifestations, including hyponatremia, lymphopenia, thrombocytopenia, and coagulopathy. Some of these manifestations can be overlooked if they overlap with manifestations of a patient’s pre-existing conditions. Case Report: A 43-year-old woman with RMSF presented with fever and treatment-resistant hyponatremia before developing a rash. Initially, the cause of her hyponatremia was attributed to adrenal insufficiency and dehydration. After appropriate treatments with hormone replacement therapy and intravenous hydration, her laboratory values remained relatively unchanged. A rash later appeared with an atypical RMSF pattern, warranting a detailed integumentary examination, which uncovered the culprit tick in an unusual location. After starting doxycycline, the patient’s signs and symptoms, including her sodium level, improved. Conclusions: We conclude that the diagnosis of RMSF is an empiric diagnosis based on clinical signs, symptoms, and appropriate epidemiologic settings for tick exposures. However, typical clinical signs do not always display at presentation. Other manifestations that a patient’s pre-existing conditions can simultaneously cause should not be overlooked and should be examined holistically with other signs, symptoms, laboratory values, and physical examinations. Early treatment with doxycycline is encouraged as evidence strongly suggests that early treatment is correlated with lower mortality.