Photo Quiz

Fever and Rash After Travel to the Philippines


Am Fam Physician. 2021 Jan 15;103(2):113-114.

A 33-year-old patient presented with a rash that developed two days earlier and was preceded by fever, headache, nausea, and arthralgias. The rash was worse on the limbs. The medical history was unremarkable, but the patient had recently traveled to the Philippines.

Physical examination revealed a diffuse, erythematous, maculopapular rash on the arms and legs (Figure 1). Findings on a tourniquet test were positive (Figure 2). Laboratory testing was positive for leukopenia and thrombocytopenia. A chest radiograph showed right-sided pleural effusion.






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

  • A. Acute HIV infection

  • B. Chikungunya virus infection.

  • C. Dengue.

  • D. Malaria.

  • E. Zika virus infection.


The answer is C: dengue, a common mosquito-borne disease encountered in more than 100 tropical and subtropical countries in North and South America, Africa, the Middle East, Asia, and the Pacific Islands. The incidence is increasing, and outbreaks are becoming more common, including in the Caribbean and the Big Island of Hawaii.1 The disease is caused by one of four dengue viruses transmitted by Aedes aegypti and Aedes albopictus mosquitos. Most cases in the United States are travel-related, except in Puerto Rico where dengue is endemic.2

Humans are the primary reservoirs for dengue. Patients with the disease may be asymptomatic or have mild to severe or life-threatening symptoms. Common presenting symptoms include high-grade fever, headache, retroorbital pain, myalgias/arthralgias, nausea, vomiting, and rash. The disease progresses to severe dengue in one out of 20 patients.1 Severe dengue

Address correspondence to Micah Pippin, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Centers for Disease Control and Prevention. Dengue. Accessed November 12, 2020.

2. Huntington MK, Allison J, Nair D. Emerging vector-borne diseases. Am Fam Physician. 2016;94(7):551–557. Accessed November 12, 2020.

3. CDC. Tourniquet test. Accessed November 12, 2020.

4. Centers for Disease Control and Prevention. Dengue. Testing guidance. Accessed November 12, 2020.

5. Daar ES, Pilcher CD, Hecht FM. Clinical presentation and diagnosis of primary HIV-1 infection. Curr Opin HIV AIDS. 2008;3(1):10–15.

6. da Cunha RVD, Trinta KS. Chikungunya virus: clinical aspects and treatment - a review. Mem Inst Oswaldo Cruz. 2017;112(8):523–531.

7. Lee VJ, et al. Simple clinical and laboratory predictors of Chikungunya versus dengue infections in adults. PLoS Negl Trop Dis. 2012;6(9):e1786.

8. Feder HM Jr., Mansilla-Rivera K. Fever in returning travelers. Accessed November 12, 2020.

9. Igbinosa II, Rabe IB, Oduyebo T, et al. Zika virus: common questions and answers. Am Fam Physician. 2017;95(8):507–513. Accessed November 12, 2020.

10. Sharp TM, Fischer M, Muñoz-Jordán JL, et al. Dengue and Zika virus diagnostic testing for patients with a clinically compatible illness and risk for infection with both viruses. MMWR Recomm Rep. 2019;68(1):1–10.

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