SAEM Clinical Images Series: Rash and Fever in a Returned Traveler

A 21-year-old otherwise healthy female presented to the Emergency Department with a fever after recently returning from Ghana. She reported intermittent fever, headache with photophobia, diarrhea, joint pains, and generalized weakness. She also noticed a diffuse, intermittently pruritic rash on her trunk and extremities. While in Ghana, she volunteered at a refugee hospital, ate street food, and was exposed to local animals. Prior to her stay in Ghana, she spent a week in Bali. She reported receiving vaccines before leaving but was unsure which vaccines she received.

Additional Images

Physical Exam

Vitals: Temp 102.9°F; HR 126; BP 114/78; RR 18; O2 sat 98% on room air

General: Uncomfortable-appearing with her eyes closed on initial exam.

HEENT: PERRL, EOMI, Normal conjunctiva without erythema; Full ROM of neck without neck stiffness/rigidity.

GI: Abdomen soft, non-tender, nondistended. No palpable masses, hepatomegaly or splenomegaly.

MSK: No evidence of joint effusion, erythema or tenderness.

Skin: Diffuse maculopapular rash to all four extremities and chest with confluent erythema noted in some areas intermixed with small areas of spread skin, scattered papules around the ankles consistent with mosquito bites.

Laboratory Data

White Blood Cell (WBC) Count: 2.78 k/mm3

Hemoglobin: 12.9 gm/dL

Hematocrit: 38 %

Platelets: 125.3/mm3

ESR: 10 mm/hr

CRP: 9.37 mg/L

AST: 42 U/L

ALT: 58 U/L

Case Question: What is the most likely diagnosis and what history and exam findings help lead you to this diagnosis?

This is a case of Dengue Fever. This diagnosis should be considered in a returning traveler from an endemic region (i.e., Asia, India, Latin America, Africa) with a fever above 40°C, retro-orbital headache, myalgias, nausea, vomiting, and/or rash. The characteristic rash associated with dengue is described as “islands of white in a sea of red”, with confluent erythema and small areas of spared skin. A bedside tourniquet test can also be performed by inflating a blood pressure cuff around the upper arm for five minutes at a pressure halfway between the patient’s systolic and diastolic blood pressure. This test is deemed positive if more than 10 petechiae are present within a square inch of skin, suggesting capillary fragility.

Case Question: What complications can be seen in severe cases of this diagnosis?

Although mild cases of dengue can be treated supportively, more severe cases typically require hospitalization. Some warning signs of severe disease include abdominal pain or vomiting, hepatomegaly, signs of volume overload including ascites or pleural effusion, and an increase in hematocrit with rapid thrombocytopenia. Severe dengue can present with shock, volume overload, severe bleeding, encephalopathy, and liver failure. Emergency physicians must keep a broad differential when evaluating fever in return travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Case Discussion

Take-Home Points

Consider Dengue Fever in patients returning from endemic regions with classic symptoms including fever, retro-orbital headache, nausea, vomiting, myalgias, and rash.
Gold standard diagnostic testing such as ELISA is often unavailable in resource-limited settings and even when available, this confirmatory result won’t be available in the acute care/emergency setting.
In patients for whom a diagnosis of Dengue Fever is suspected based on history and physical exam, the tourniquet test provides a rapid beside analysis to aid in patient diagnosis and management.

References

Schaefer TJ, Panda PK, Wolford RW. Dengue fever. StatPearls. Updated November 14, 2022. Accessed August 5, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430732/? report=reader.
Kenzaka T, Kumabe A. Skin rash from dengue fever. BMJ Case Rep. 2013: bcr2013201598.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.