A 32-year-old Korean woman presented with a 3-week history of generalized maculopapules, fever, malaise, and cervical lymph node enlargement. She had been treated with antibiotics and antipyretics at local clinics. However, she had progressively worsening cutaneous lesions and cervical lymphadenopathy, along with intermittent fever.
Physical examination revealed several rubbery, palpable, nontender lymph nodes on the right side of the neck and a temperature of 38.2°C. Cutaneous examination showed erythematous to brown confluent macules and papules over the neck, trunk, and extremities (Figure 1). Laboratory tests showed elevated levels of C-reactive protein (3.38 mg/dL; reference range, 0-0.6 mg/dL) and lactate dehydrogenase (645 IU/L; reference range, 120-250 IU/L). IgG antibody for Epstein-Barr virus (EBV) viral capsid antigen was positive on enzyme immunoassay (optical density ratio, 4.5; reference value, <1), as was EBV-determined nuclear antigen, which implied a latent infection with EBV. However, the results of other serologic tests, including IgM antibody for EBV early antigen and IgM antibody for EBV-determined nuclear antigen, were negative. Blood and urine cultures yielded no bacterial growth. Computed tomography of the neck showed multiple, contrast-enhancing, enlarged lymph nodes in the right cervical area. Biopsy specimens were obtained from the trunk (Figure 2) and from a cervical lymph node (Figure 3).