Photo Quiz
Rash and Fever in a College Student
Am Fam Physician. 2011 Sep 15;84(6):697-698.
A 21-year-old female college student presented to the hospital with rash and high fever. Severe arthralgias and a nonpruritic rash appeared on her lower extremities (Figure 1) shortly after the pharyngitis developed. The rash migrated to her chest and head (Figure 2) a few days later.
Figure 1.
Figure 1.
Figure 2.
Figure 2.
Question
Based on the patient's history and physical examination, which one of the following is the most likely diagnosis?
A. Disseminated tinea corporis.
B. Erythema marginatum.
C. Erythema migrans.
D. Erythema multiforme.
E. Erythema nodosum.
Discussion
The correct answer is B: erythema marginatum. Erythema marginatum is an evanescent, nonpruritic rash that typically occurs on the trunk and extremities, but does not usually affect the face.1 The patient's throat culture was positive for Streptococcus pyogenes, and her antistreptolysin O titers were elevated. The rash and arthralgias resolved within a few days of treatment with high-dose aspirin and penicillin.
Erythema marginatum occurs in patients who have rheumatic fever, and it is a major part of the Jones criteria for the diagnosis of rheumatic fever. Rheumatic fever can cause rheumatic heart disease and requires prompt diagnosis and treatment.2
Tinea corporis (ringworm) does not disseminate and is not associated with any systemic signs of infection. The rash typically has a fine scale and may cause alopecia. Lesions have central clearing and slightly raised borders, and are often pruritic.
Erythema migrans has a bull's-eye appearance and is a sign of Lyme disease. Like erythema marginatum, erythema migrans lesions have central clearing, but usually expand rather than migrate. Erythema migrans lesions typically have central erythema and necrosis.
Erythema multiforme is a maculopapular rash that is usually located on the palms and feet, although it can have generalized spreading. It can result from a drug reaction (e.g., sulfa, phenytoin [Dilantin], penicillins) or from viral and bacterial infections. Erythema multiforme can have a bull's-eye appearance, but it is usually pruritic and blanches away slowly.
Erythema nodosum leads to erythematous macules that are often painful. The rash most commonly occurs on the shins. There is usually no central clearing.
Summary Table
| Condition | Characteristics |
|---|---|
Tinea corporis | Ringworm lesions with central clearing and slightly raised borders; often pruritic |
Erythema marginatum | Evanescent, nonpruritic rash usually on the trunk and extremities; occurs with rheumatic fever |
Erythema migrans | Bull's-eye appearance; central erythema and necrosis; expands rather than migrates |
Erythema multiforme | Maculopapular rash usually on the palms and feet; often pruritic and blanches away slowly |
Erythema nodosum | Erythematous macules usually on the shins; no central clearing; often painful |
Summary Table
| Condition | Characteristics |
|---|---|
Tinea corporis | Ringworm lesions with central clearing and slightly raised borders; often pruritic |
Erythema marginatum | Evanescent, nonpruritic rash usually on the trunk and extremities; occurs with rheumatic fever |
Erythema migrans | Bull's-eye appearance; central erythema and necrosis; expands rather than migrates |
Erythema multiforme | Maculopapular rash usually on the palms and feet; often pruritic and blanches away slowly |
Erythema nodosum | Erythematous macules usually on the shins; no central clearing; often painful |
REFERENCES
1. Nonsuppurative poststreptococcal sequelae: rheumatic fever and glomerulonephritis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Edinburgh, Scotland: Elsevier Churchill Livingstone; 2005: 2380–2392.
2. Ferrieri P; Jones Criteria Working Group. Proceedings of the Jones criteria workshop. Circulation. 2002;106(19):2521–2523.
Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.
A collection of Photo Quizzes published in AFP is available at https://www.aafp.org/afp/photoquiz.
The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at https://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.
Copyright © 2011 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact
afpserv@aafp.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions
More in AFP
Editor's Collections
Related Content
More in Pubmed
MOST RECENT ISSUE
Email Alerts
Don't miss a single issue. Sign up for the free AFP email table of contents.
