In SFG rickettsioses, subcutaneous necrosis and digital gangrene most likely related to small-vessel occlusion have been described in severe late stage infections caused by Rickettsia rickettsii (Rocky Mountain spotted fever) and Rickettsia conorii [8–11]. Such severe form of skin involvement is described as Purpura fulminans (PF) and include a heterogeneous group of disorders characterized by rapidly progressive purpuric lesions that may develop into extensive areas of skin necrosis, and peripheral gangrene. This rare disorder is associated with laboratory evidence of consumptive coagulopathy and is often fatal . PF is usually associated with many infections, most notably with meningococcal, staphylococcal, streptococcal infections in addition to SFG rickettsioses . Probable less severe or early form of PF; termed as “fern leaf pattern” skin rash has been previously reported in elderly patients with SFG rickettsiosis in the central hills of Sri Lanka [3, 6, 7, 12].