1st Place Emage Winner: Common Looking Viral Rash Caused by an Infection Not Typical in the Northeast USA

Godfrey Jay Tutay, MD

Vivek Sharma, DO

Department of Emergency Medicine

NYU Langone Hospital

Long Island, New York

Patient Presentation

The patient is a 13-year-old male, previously healthy and fully immunized, who was referred by their pediatrician, for further evaluation of a rash and history of nosebleed. The patient and family traveled to the British Virgin Islands from February 14 to February 22, 2024, and reported being bitten by mosquitoes multiple times. Five days prior to presentation (February 23), the patient began experiencing fevers with the highest temperature of 102°F. The fevers persisted for 3 days but subsided 2 nights prior to presentation. The patient experienced a nosebleed the night before presentation that stopped spontaneously after several minutes. On the day of presentation, the patient noted a rash to his hands that spread to his arms and chest with improvement of the chest rash. He also noted rash on his feet and right upper thigh with the rash on the thigh now resolved. 

Upon examination, the patient looks well and is not in distress. He did not have any active nosebleed and no bleeding from the gums and mouth.  He presented with a red flat rash on his hands, wrists, and feet that blanches with pressure, as pictured below. He does not have any petechiae or purpura.

Investigation

We requested a complete blood count (CBC), comprehensive metabolic panel, and Dengue Fever Virus antibodies IgM and IgG. The CBC was significant for low white blood cell (WBC) count of 2,900/uL with 19% atypical lymphocytes and slightly low platelets of 140,000 /uL. The AST was slightly elevated at 39 IU/L. After 2 days, the result of Dengue Fever antibodies IgM was showing an elevated level of 3.51 (negative IgM test is 1.64 and equivocal test is 1.65-2.84), confirming the diagnosis.

Clinical Lesson

Dengue fever is an infection caused by one of four dengue viruses transmitted by Aedes mosquito. During the febrile phase, a rash generally develops 2 to 5 days after the onset of fever. The rash is usually described as a typical macular or maculopapular rash over the face, thorax, abdomen, and extremities. Rash may be pruritic. Our patient presented with rash after 5 days of the onset of fever, and 2 days later the fever was gone. The rash was very subtle and mostly localized to the hands, wrist, and feet by the time he presented to the emergency department. This case highlights the importance of considering travel history and endemic infectious diseases in the differential diagnosis of febrile illness with rash in patients with recent travel history in regions where such diseases are prevalent.

Reference

1. Thomas SJ, Rothman AL, Srikiatkhachorn A, Kalayanarooj S (2024). Dengue virus infection: Clinical manifestation and diagnosis. In: UpToDate, Hirsch MS, Hall KK (Eds). Available from: https://www.uptodate.com/contents/dengue-virus-infection-clinical-manifestations-and-diagnosis?search=dengue%20fever&source=search_result&selectedTitle=1%7E111&usage_type=default&display_rank=1#H2508477551 (Accessed May 21, 2024).