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JAMA Dermatology Clinicopathological Challenge
December 2013

Flagellate Erythema in a Patient With Fever

Author Affiliations
  • 1Division of Dermatology, Department of Internal Medicine, Washington University School of Medicine, St Louis, Missouri

Copyright 2013 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Dermatol. 2013;149(12):1425-1426. doi:10.1001/jamadermatol.2013.4457

A woman in her 40s presented with a 6-month history of intermittent fevers, malaise, polyarthralgias, sore throat, and a pruritic exanthem on her trunk, scalp, and extremities. A previous biopsy was nonspecific. She had no significant medical history.

Physical examination revealed erythematous, mildly scaly plaques in a shawl distribution (Figure, A) and hyperpigmented, erythematous, excoriated papules in a linear arrangement on her back (Figure, B) and lower extremities. Laboratory studies showed leukocytosis (27 900/uL, 95% neutrophils) and increased levels of C-reactive protein (344 mg/L) and ferritin (63 000 ng/mL). Antinuclear antibody titer was 1:80. Findings for rheumatoid factor and antineutrophil cytoplasmic antibodies were negative, as were those for Lyme disease, rickettsial disease, cytomegalovirus, Bartonella, rapid plasma reagin, human immunodeficiency virus, and hepatitis. Serum and urine protein electrophoresis findings were also negative, and chest, abdomen, and pelvic computed tomography showed nonspecific hilar lymphadenopathy. A punch biopsy specimen from the back was obtained (Figure, C).

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