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JAMA Clinical Challenge
February 14, 2017

Fever and a Pustular Rash

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
JAMA. 2017;317(6):637-638. doi:10.1001/jama.2016.18020

A previously healthy man in his 40s presented with 4 days of fever and a rash. He noticed multiple acneiform papules and pustules around the neckline that progressed to involve the face, torso, and limbs. He took no prescribed medications but had taken an ibuprofen pill a week prior for a mild headache; his symptoms started 3 days after that. He had no sick contacts or recent travel and reported no use of alcohol or tobacco.

On examination, he was febrile (38.9°C) and tachycardic but normotensive. Clusters of pustules, approximately 1 mm in diameter, were present over an erythematous base overlying the face, neck, chest, back, and arms (Figure). Laboratory analysis revealed values within normal ranges for hemoglobin (13.1 g/dL) and platelet count (186 ×109/L); an elevated white blood cell count (22.3 x109/L; 82% neutrophils, 9% lymphocytes, 5% eosinophils, 4% monocytes); erythrocyte sedimentation rate of 58 mm/h (reference range, 0-20); C-reactive protein level of 232 mg/L (2210 nmol/L) (reference, <5 mg/dL [48 nmol/L]); and normal renal and hepatic function. Gram stain of the pustule fluid revealed no organisms, and cultures of the blood and pustule fluid were without growth. A punch biopsy of the skin lesions showed subcorneal pustules containing neutrophils and eosinophils, with epidermal spongiosis.

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