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A 30-Year-Old Woman With Fever and a Rash

  • Authors: Andrea Bianchin, MD; Moreno Agostini, MD
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This activity is intended for clinicians in primary care, emergency care, and infectious diseases.

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  1. Describe the typical presentation and management of a commonly encountered medical condition in clinical practice.


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  • Andrea Bianchin, MD

    Andrea Bianchin, MD, Intensive Care Unit (Anestesia e Rianimazione), Presidio Ospedaliero di Montebelluna, Azienda U.LSS. n.8 di Asolo, Montebelluna (TV), Italy


    Disclosure: Andrea Bianchin, MD, has disclosed no relevant financial relationships.

  • Moreno Agostini, MD

    Moreno Agostini, MD, Director, Intensive Care Unit (Anestesia e Rianimazione), Presidio Ospedaliero di Montebelluna, Azienda U.LSS. n.8 di Asolo, Montebelluna (TV), Italy


    Disclosure: Moreno Agostini, MD, has disclosed no relevant financial relationships.


  • Laurie E. Scudder, MS, NP-C

    Nurse Planner, Medscape; Adjunct Assistant Professor, School of Health Sciences, George Washington University, Washington, DC;  Curriculum Coordinator, Nurse Practitioner Alternatives, Inc., Ellicott City; Nurse Practitioner,  Baltimore City School-Based Health Centers, Baltimore, Maryland


    Disclosure: Laurie E. Scudder, MS, NP-C, has disclosed that she has no relevant financial relationships.


  • Rick G. Kulkarni, MD, FACEP

    Rick G. Kulkarni, MD, FACEP, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, CT


    Disclosure: Rick G. Kulkarni, MD, FACEP, has disclosed no relevant financial relationships.

  • Erik D. Schraga, MD

    Erik D. Schraga, MD, Clinical Instructor of Emergency Medicine, Stanford/Kaiser Emergency Medicine Residency Program, Department of Emergency Medicine, Kaiser Permanente, Santa Clara Medical Center, Santa Clara, CA


    Disclosure: Erik D. Schraga, MD, has disclosed no relevant financial relationships.

  • Michael S. Bronze, MD

    Michael S. Bronze, MD, Stewart Wolf Professor, Chairman of the Department of Medicine, University of Oklahoma Health Science Center, Oklahoma City, OK


    Disclosure: Michael S. Bronze, MD, has disclosed no financial relationships.

  • Luis M. Soler, BA

    Luis M. Soler, BA, Associate Editor, eMedicine/WebMD, New York, NY


    Disclosure: Luis M. Soler, BA, has disclosed no relevant financial relationships.

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A 30-Year-Old Woman With Fever and a Rash

Authors: Andrea Bianchin, MD; Moreno Agostini, MDFaculty and Disclosures


A 30-Year-Old Woman With Fever and a Rash


Figure 1.
(Click to enlarge)

Figure 2.
(Click to enlarge)

A 30-year-old woman presents to the emergency department (ED) with malaise, diffuse myalgia, and a rash that has spread all over her body (see Figures 1 and 2). Her symptoms began the day before presentation and initially improved with ibuprofen. Her boyfriend, who has accompanied her to the ED, adds that she has been vomiting, has appeared to be in pain with movement, and has even had intermittent confusion during the night. She has developed a headache of moderate intensity that is diffuse, radiating to her neck, and worsens with movement. She does not have any photophobia or dizziness, and she has not experienced any seizures. She denies having any subjective fevers, abdominal pain, hematemesis, or diarrhea. She has not had any urinary complaints or low back pain. She denies having cough or shortness of breath. The patient's past medical history is only remarkable for trauma that occurred 3 months ago and resulted in rib fractures and blunt abdominal trauma. At that time, she underwent an exploratory laparotomy, with suture repair of liver lacerations and a right kidney laceration; she has been doing well since then. The patient does not have any chronic medical conditions and does not take any regular medications. She smokes cigarettes but denies heavy alcohol use or illicit drug use.

On physical examination, she appears drowsy and uncomfortable. Her oral temperature is 100.9°F (38.3°C). She is tachycardic and hypotensive, with a heart rate of 120 bpm and a blood pressure of 80/60 mm Hg. Her respiratory rate and oxygen saturation are normal (at 16 breaths/min and 99% while breathing room air, respectively). She grimaces in pain with movement of the joints, particularly with movement of her neck, which is limited. Her pupils are 3 mm and equally reactive. Her neurologic examination, including a cranial nerve inspection, is normal (except for her drowsy mental status). She has a nonpainful purpuric rash on her arms, trunk, and face consisting of patchy macules approximately 1-4 cm in diameter (see Figures 1 and 2). There is no cervical, axillary, or inguinal lymphadenopathy. Her lungs are clear and her heart sounds are normal, without any murmurs or gallops. She has a soft and nontender abdomen, with no splenomegaly. There is no midline spinal tenderness or costovertebral angle tenderness. There is no evidence of joint involvement, and no tenderness or swelling are noted. The remainder of the examination is unremarkable.

Laboratory studies show an elevated white blood cell (WBC) count of 17.6 × 103/µL (17.6 × 109/L), a hemoglobin of 13.6 g/dL (136 g/L), and a platelet count of 54 × 103/µL (54 × 109/L). Her creatinine is 3.3 mg/dL (291.7 µmol/L) and her blood urea nitrogen (BUN) is 57 mg/dL (20.4 mmol/L). The electrolyte concentrations and hepatic studies are normal. The patient's myoglobin and creatine kinase concentrations are elevated at 332 µg/L and 149 U/L (149 units/L), respectively. The C-reactive protein (CRP) is high at 22 mg/dL. Her partial thromboplastin time (PTT) is elevated at >120 seconds, with an international normalized ratio (INR) of 2.14. The d-dimer is markedly elevated at >10 µg/mL (10 mg/L). Her serum pregnancy test is negative. An arterial blood gas shows a pH of 7.3, a lactate of 64.9 mg/dL (7.2 mmol/L), a partial pressure of carbon dioxide (pCO2) of 35.4 mm Hg, a partial pressure of oxygen (pO2) of 318 mm Hg, and an oxygen saturation of 99.3% while using an oxygen mask at 10 L/min. Blood cultures are drawn and sent to the laboratory.