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JAMA Clinical Challenge
December 25, 2018

Fever, Rash, and Abnormal Liver Function Test Results

Author Affiliations
  • 1Department of Medicine, Okinawa Miyako Hospital, Okinawa, Japan
JAMA. 2018;320(24):2591-2592. doi:10.1001/jama.2018.16143

A previously healthy man in his 30s presented with a 5-day history of fever, anorexia, and rash. Five days before arrival, he developed throat pain, rhinorrhea, nonproductive cough, and fever. Two days later he noticed a maculopapular rash on his neck and trunk, which later involved his upper and lower extremities. He did not smoke and only drank alcohol occasionally. He was living in Japan and recently visited a neighboring island but denied any international travel.

On examination, his blood pressure was 142/84 mm Hg; temperature, 38.3°C; pulse, 91/min; respiratory rate, 24/min; and oxygen saturation, 97% on ambient air. He was alert and oriented. There were no mucosal lesions or conjunctival injection. A maculopapular rash was noted on the trunk and extremities (Figure) as well as the palms and soles. The face was not involved. The lungs were clear to auscultation. No hepatosplenomegaly was noted. Neurologic examination, including results of motor, sensory, and reflex testing, was unremarkable. There was no neck stiffness or lymphadenopathy. Laboratory testing showed a white blood cell count of 2900/μL (80% neutrophils, 13% lymphocytes, 6% monocytes, 0% eosinophils, and 0% basophils); hemoglobin level, 15.2 g/dL; and platelet count, 187 ×103/μL. Serum electrolyte levels were normal. Aspartate aminotransferase level was 635 U/L (10.6 μkat/L); alanine aminotransferase (ALT), 491 U/L (8.2 μkat/L); lactate dehydrogenase, 807 U/L (13.48 μkat/L); γ-glutamyltransferase, 329 U/L (5.49 μkat/L); and bilirubin, 1.3 mg/dL (22.24 μmol/L).