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Lack of efficacy: case report A 19-year-old woman experienced lack of efficacy during treatment with doxycycline for Rickettsiosis and norepinephrine for cardiovascular instability secondary to Rickettsiosis. The primiparous woman at 37 weeks of gestation presented to a clinic with fever and a 1-day history of transvaginal fluid output, asthenia and adynamia. At presentation, intrauterine growth restriction and oligohydramnios were noted. She was then transferred to second-level hospital. She denied any history of substance abuse, allergies, zoonosis or chronic degenerative diseases. Her blood group was O positive, and she had completed all immunisations. She had not travelled recently before the admission. She was on prenatal control and had been receiving folic acid and ferrous fumarate regularly. After investigation, the findings were corroborated, and foetal monitoring was started. Additionally, she received antibiotic treatment with ceftriaxone 1g every 12 hours, followed by an immediate surgical intervention. The surgery was without any complications, with bleeding of 600mL. Oligohydramnios was confirmed by the minimal efflux of amniotic fluid, euthermic uterine cavity and no odour. She delivered a live male newborn male weighing 2600g with Apgar score of 8-9, and without any intraoperative complications. After 12 hours of the surgery, investigation revealed reduced platelets and transaminases elevated to double the upper limit of normal. At that time, a differential diagnosis of HELLP syndrome was considered, and treatment with steroids and platelet concentrates [specific drugs not stated] was initiated. However, her clinical condition deteriorated in the following 2 days, which was accompanied by respiratory distress due to hypoxia. Subsequently, she was shifted to an ICU. In the ICU, a relative told that she had been in contact with ticks within the previous two weeks. Therefore, the diagnosis of Rickettsiosis was considered. Febrile peaks were confirmed within the earlier 48 hours, as well as cardiovascular instability in correlation with septic shock. Therefore, fluid resuscitation and vasopressor norepinephrine [dosage not stated] infusion was initiated and maintained. After that, serum cultures were taken for Rickettsiosis PCR study. Because of the high suspicion of an infectious process due to Rickettsia and the clinical behaviour with gradual deterioration, she was initiated on IV doxycycline 100mg every 12 hours empirically. Despite the administration of vasopressors, her haemodynamic deterioration continued. Therefore, hydrocortisone and albumin were immediately started as an alternate measure to prevent the excessive administration of intravenous solutions. On next day, Rickettsiosis was confirmed by PCR, and the current antibiotic scheme of doxycycline treatment was continued. Despite specific treatment, she developed disseminated intravascular coagulopathy followed by fatal multiple organ failure on day 5 of hospital admission. Moreno-Trujillo M, et al. Rickettsiosis vs HELLP syndrome. A cl