Generalized maculopapular rash and fever

The differential for rash and fever is broad

Syphilis also can manifest with rash and fever. The rash of syphilis is nonpainful and affects the torso and face, with concentration on the palms and soles.^6,7It manifests during syphilis’s secondary stage, 6 to 8 weeks after an untreated infection. Fatigue, malaise, lymphadenopathy, mucosal lesions, ocular symptoms, and nephritis can occur.^8,9 The diagnosis is made through treponemal-specific antibody confirmation of a positive rapid plasma reagin test.⁹ Neurosyphilis is diagnosed via lumbar puncture.⁹

Dermatomyositis is a rare disorder of inflammation in both the skin and muscles. Symptoms include rash, muscle aches, and weakness. Lab abnormalities include elevated creatine kinase levels and ANA. Muscle biopsy confirms the diagnosis.

Erythema multiforme is an ­immunologic-mediated rash consisting of firm targetoid erythematous papules distributed symmetrically on the extremities, including palms/soles. It typically appears after a viral infection, immunization, or new medications (eg, antibiotics, nonsteroidal anti-­inflammatory drugs, or phenothiazines) initiated 1 to 3 weeks prior to the appearance of the rash. History and appearance inform the diagnosis.

Polymorphic light eruption is a rash of variable appearance on sun-exposed areas that results from a sensitivity to sunlight after lack of exposure for a period of time. Symptoms include burning and itching.

Treatment and outcome

Treat patients with SLE with hydroxychloroquine (200-400 mg/d) to suppress inflammation and with low-dose oral steroids such as prednisone (7.5 mg/d) for intermittent exacerbations. Higher steroid doses are sometimes needed for signs of organ inflammation. Patients with increased disease activity will require immunosuppressive therapy with ­disease-modifying antirheumatic drugs, such as methotrexate (7.5-25 mg/wk), mycophenolate (2-3 g/d), azathioprine (1.5-2.5 mg/kg/d), and biologic infusions.⁴ Additionally, in 2021, the US Food and Drug Administration approved anifrolumab (Saphnelo) and voclosporin (Lupkynis) for the treatment of SLE.⁴

Our patient was admitted for further evaluation. A lumbar puncture was performed because of his balance issues; it showed an elevated protein level, but further work-up did not find an infectious or malignant source. Balance improved with hydration. The patient remained hospitalized for 9 days, during which his fever subsided. His pain improved after initiation of hydroxychloroquine 400 mg/d. Follow-up with Rheumatology was arranged for further care.