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Lower Extremity Rash Presenting After a Trip to South Africa

 


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Am Fam Physician. 2016 Jun 15;93(12):1021-1024.

A 69-year-old man presented with unsteadiness, fever, chills, and a rash on his right lower extremity. He had recently returned from a trip to South Africa. He developed nausea and vomiting secondary to his disequilibrium, as well as blurry vision. After treatment with cephalexin (Keflex), ceftriaxone, and cefpodoxime, there was no improvement in the rash or associated symptoms. He did not develop leukocytosis. The patient was an arborist and had close contact with trees and other vegetation. While he was in South Africa, he went on safaris outside of urban areas.

On physical examination, the patient had a horizontal nystagmus with lateral gaze bilaterally. There were two aphthous ulcers on the buccal mucosa. There was a scattered, blanching maculopapular rash on his anterior and posterior trunk and his extremities. There was also a deeply erythematous, macular, conluent nonblanching rash on the right lower extremity that was circumferential (Figure 1). The rash was warm and tender to palpation. A satellite lesion appeared as a pustular eschar with a surrounding rim of erythema (Figure 2), superior to the right lateral malleolus.


Figure 1.


Figure 2.

Question

Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. African tick-bite fever.

B. Cellulitis with superimposed drug exanthem.

C. Lyme disease.

D. Rocky Mountain spotted fever.

E. Thrombotic thrombocytopenic purpura.

Address correspondence to Diana Wilkins, MD, at dgpratt@buffalo.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Owen C, Bahrami S, Malone JC, Callen JP, Kulp-Shorten CL. African tick bite fever: a not-so-uncommon illness in international travelers. Arch Dermatol. 2006;142(10):1312–1314....

2. Jensenius M, Fournier PE, Vene S, et al. African tick bite fever in travelers to rural sub-Equatorial Africa. Clin Infect Dis. 2003;36(11):1411–1417.

3. Chapman AS, Bakken JS, Folk SM, et al. Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis—United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep. 2006;55(RR–4):1–27.

4. Bohaty BR, Hebert AA. Images in clinical medicine: African tick-bite fever after a game-hunting expedition. N Engl J Med. 2015;372(10):e14.

5. Bouvresse S, Del Giudice P, Franck N, et al. Two cases of cellulitis in the course of African tick bite fever: a fortuitous association? Dermatology. 2008;217(2):140–142.

6. Herchline TE. Cellulitis. Updated August 19, 2015. Medscape. http://emedicine.medscape.com/article/214222-overview. Accessed March 24, 2016.

7. Blume J. Drug eruptions. Updated October 9, 2015. Medscape. http://emedicine.medscape.com/article/1049474-overview. Accessed March 24, 2016.

8. Meyerhoff J. Lyme disease. Updated March 15, 2016. Medscape. http://emedicine.medscape.com/article/330178-overview. Accessed March 24, 2016.

9. Rathore MH. Rickettsial infection. Updated October 7, 2015. Medscape. http://reference.medscape.com/article/968385-clinical#b4. Accessed March 24, 2016.

10. Wun T. Thrombotic thrombocytopenic purpura. Updated November 18, 2015. Medscape. http://emedicine.medscape.com/article/206598-overview. Accessed March 24, 2016.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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