Fever and Rash After Travel to the Philippines - Photo Quiz - American Family Physician
 
 

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.

FIGURE 1


FIGURE 1

FIGURE 2


FIGURE 2

Question

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.

Discussion

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 follows three phases: febrile, critical, recovery. The critical phase occurs after 72 hours of fever and is distinguished by increased vascular permeability, fever, hemorrhagic manifestations, and marked thrombocytopenia.

Diagnosis of dengue is based on clinical signs and symptoms. The tourniquet test is commonly used.3 To perform this test, a blood pressure cuff is inflated on the arm, then removed. After two minutes, petechiae are counted below the antecubital fossa. The test is positive if there are 10 or more petechiae per 1 square inch (Figure 2). The Centers for Disease Control and Prevention recommends testing symptomatic patients with a history of travel to endemic areas.4

Acute HIV infection, also known as primary HIV infection or acute retroviral syndrome, is the period just after initial HIV infection, generally before seroconversion.5 Symptoms are characterized as mononucleosis-like or flulike, with the most prevalent symptoms being fever, fatigue, myalgias/arthralgias, rash, pharyngitis, lymphadenopathy, and mucocutaneous ulcerations.5

Chikungunya virus infection and dengue have similar symptoms and are transmitted by the same mosquito vectors.6 Chikungunya virus infection is characterized by fever and intense joint pain but lacks leukopenia and thrombocytopenia. Headache, myalgias, and rash are also possible.7 The laboratory diagnosis of Chikungunya virus infection is based on viral isolation.6

Malaria is a parasitic infection. In the United States, malaria mainly occurs in travelers who have returned from endemic regions.8 Fever and splenomegaly are the most common physical examination findings.8

Zika virus infection also presents similarly to dengue and is transmitted by the same mosquito vectors.9 Unlike dengue, Zika virus infection is commonly associated with conjunctivitis.9 The disease is diagnosed through serology or reverse transcriptase–polymerase chain reaction testing.10

 Enlarge     Print

SUMMARY TABLE

ConditionCharacteristicsSigns and symptoms

Acute HIV infection

Period just after initial HIV infection, generally before seroconversion; also called primary HIV infection or acute retroviral syndrome

Mononucleosis-like or flulike; fever, fatigue, myalgias/arthralgias, rash, pharyngitis, lymphadenopathy, and mucocutaneous ulcerations

Chikungunya virus infection

Similar to dengue but lacks leukopenia and thrombocytopenia; transmitted by same mosquito vectors as dengue

Fever and intense joint pain; headache, myalgias, and rash are also possible

Dengue

Can be diagnosed using the tourniquet test; severe illness has three phases: febrile, critical, and recovery; transmitted by Aedes aegypti and Aedes albopictus mosquitos

High-grade fever, headache, retroorbital pain, myalgias/arthralgias, nausea, vomiting, and rash

Malaria

Parasitic infection

Fever and splenomegaly

Zika virus infection

Transmitted by same mosquito vectors as dengue; can cause birth defects, such as microcephaly, if the mother is infected during pregnancy

Often asymptomatic; if present, symptoms are similar to dengue, but conjunctivitis is more common

SUMMARY TABLE

ConditionCharacteristicsSigns and symptoms

Acute HIV infection

Period just after initial HIV infection, generally before seroconversion; also called primary HIV infection or acute retroviral syndrome

Mononucleosis-like or flulike; fever, fatigue, myalgias/arthralgias, rash, pharyngitis, lymphadenopathy, and mucocutaneous ulcerations

Chikungunya virus infection

Similar to dengue but lacks leukopenia and thrombocytopenia; transmitted by same mosquito vectors as dengue

Fever and intense joint pain; headache, myalgias, and rash are also possible

Dengue

Can be diagnosed using the tourniquet test; severe illness has three phases: febrile, critical, and recovery; transmitted by Aedes aegypti and Aedes albopictus mosquitos

High-grade fever, headache, retroorbital pain, myalgias/arthralgias, nausea, vomiting, and rash

Malaria

Parasitic infection

Fever and splenomegaly

Zika virus infection

Transmitted by same mosquito vectors as dengue; can cause birth defects, such as microcephaly, if the mother is infected during pregnancy

Often asymptomatic; if present, symptoms are similar to dengue, but conjunctivitis is more common

Address correspondence to Micah Pippin, MD, at mpipp2@lsuhsc.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Centers for Disease Control and Prevention. Dengue. Accessed November 12, 2020. https://www.cdc.gov/dengue/index.html...

2. Huntington MK, Allison J, Nair D. Emerging vector-borne diseases. Am Fam Physician. 2016;94(7):551–557. Accessed November 12, 2020. https://www.aafp.org/afp/2016/1001/p551.html

3. CDC. Tourniquet test. Accessed November 12, 2020. https://www.cdc.gov/dengue/training/cme/ccm/page73112.html

4. Centers for Disease Control and Prevention. Dengue. Testing guidance. Accessed November 12, 2020. https://www.cdc.gov/dengue/healthcare-providers/testing/testing-guidance.html

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. https://www.aafp.org/afp/2013/1015/p524.html

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. https://www.aafp.org/afp/2017/0415/p507.html

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.

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 © 2021 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

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Mar 1, 2021

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article