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Progressive Rash Involving the Hands and Feet


Am Fam Physician. 2018 Jun 15;97(12):815-817.

An otherwise healthy 34-year-old man presented in late fall with a progressive rash that started four days earlier on his hands and then spread to his arms, back, chest, and feet. The rash was mildly pruritic but nontender. He had gingival soreness. He had a mild upper respiratory tract infection one week prior that resolved. He had no recent changes in detergents, soaps, or shampoos. He had no constitutional symptoms.

He went hiking in Pennsylvania five days before the rash appeared, but he did not report any insect bites and had not traveled outside the United States. The patient had one long-term sex partner and no other sexual contacts or history of sexually transmitted infections.

On physical examination, the patient was afebrile. He had multiple blanching, erythematous papules and vesicles on his hands (Figure 1), chest, back (Figure 2), and feet. A swollen, tender left inguinal lymph node was noted. There were no oral lesions.

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

A. Coxsackie virus infection.

B. Herpes simplex virus infection.

C. Measles.

D. Rickettsia rickettsii infection.

E. Treponema pallidum infection.


The answer is D: Rickettsia rickettsii infection. R. rickettsii is a gram-negative bacterium that causes Rocky Mountain spotted fever. It is transmitted from the bites of various tick species, but one-third of patients with the infection do not report tick bites. Five states (North Carolina, South Carolina, Tennessee, Oklahoma, and Arkansas) account for more than 60% of spotted rickettsial disease cases in the United States.1

Rickettsial disease presents as fever, headaches, myalgias, and gastrointestinal symptoms within two weeks after a tick bite followed by the classic rash, which is characterized by erythematous macules that start around the wrists and ankles and spread across the body. The rash includes papular lesions on the palms and soles but spares the face. However, the rash does not develop in up to 12% of patients.2 In severe cases, a petechial rash can result from the disseminated infection affecting endothelial cells, leading to increased vascular

Address correspondence to Andy Chern, MD, MPH, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. government.


show all references

1. Centers for Disease Control and Prevention. Rocky Mountain spotted fever (RMSF). Accessed July 11, 2017....

2. Dantas-Torres F. Rocky Mountain spotted fever. Lancet Infect Dis. 2007;7(11):724–732.

3. Bolognia J. Dermatology. 3rd ed. Philadelphia, Pa.: Elsevier Saunders; 2012.

4. James WD, Berger TG, Elston DM. Andrews' Diseases of the Skin: Clinical Dermatology. 12th ed. Philadelphia, Pa.: Elsevier; 2016.

5. Watson JC, Hadler SC, Dykewicz CA, Reef S, Phillips L. Measles, mumps, and rubella—vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1998;47(RR-8):1–57.

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

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