Presentation of Case
Dr. Anne L. Piantadosi (Infectious Diseases): A 27-year-old woman was seen in the emergency department of this hospital during the summer because of arthralgias and a rash.
The patient had been well until 5 days before this evaluation, when arthralgias in her fingers, hands, and shoulders developed, along with back pain, neck pain, and a retro-orbital headache. Later that day, fever occurred (temperature, 39.0°C) and was accompanied by chills, nausea, decreased appetite, sore throat, and mild redness of her eyes. She also noted a vaginal ulcer, ulcers on the side of her tongue, decreased taste sensation, and enlarged, tender lymph nodes in her neck and groin. The next morning, the patient awoke with a rash on her right forearm. The lesions were pink, pruritic, and nonpainful; some were flat and others were raised, resembling hives. Within 1 hour, the rash spread to her torso and both arms and legs. She presented to the emergency department of another hospital, where a viral illness was diagnosed on the basis of her clinical presentation; she was discharged home.
The following day, the patient’s arthralgias persisted and involved not only her fingers, hands, and shoulders but also her elbows, knees, ankles, and toes. Swelling in her wrists and hands led her to remove a bracelet and her wedding ring. Her gums bled easily when she brushed her teeth. By that evening, her fever, headache, and rash had remitted. Over the next 2 days, the arthralgias persisted but all other symptoms continued to abate. On the fifth day of illness, a new pruritic, erythematous rash developed, beginning on her palms and spreading to her arms, chest, abdomen, back, and legs, sparing the soles of her feet. The patient took ibuprofen and diphenhydramine and then presented to the emergency department of this hospital for evaluation.
The patient had a remote history of appendectomy. Her only medication was a daily multivitamin, and she had no known allergies. Immunizations were reportedly current. She lived with her husband in a suburban area of New England, worked as a chemical engineer, and enjoyed running. Three days before the onset of illness, the patient had returned from a 7-day trip to the Turks and Caicos Islands, where she spent time on the beach and received multiple mosquito bites. She was monogamous with her husband, consumed alcohol in moderation, did not smoke or use illicit drugs, and had no exposure to sick persons. There was no family history of autoimmune disease.