Every Nook and Cranny

A 46-year-old man presented to the emergency room in the postmonsoon month of September with a seven-day history of high fevers as well as a four-day history of a dry cough, dyspnea, and progressive rash. The patient reported no chest pain, hemoptysis, chest tightness, palpitations, wheezing, orthopnea, paroxysmal nocturnal dyspnea, or leg swelling. He lived and sought healthcare in Delhi, India.

Fever followed by a progressive but as yet uncharacterized rash and pulmonary symptoms in a middle-aged man suggests a host of possibilities. While it is tempting to ascribe his symptoms to an infectious process, especially a “tropical” infection based on his residence in Delhi, the location may simply represent a red herring. Potential infections can be divided into those endemic to the Indian subcontinent, and those encountered more globally. The former include diseases such as measles and dengue, while the latter include entities such as Mycoplasma pneumonia, varicella, and acute human immunodeficiency virus (HIV) infection. Noninfectious categories of diseases that should be considered include drug reactions and rheumatologic processes. Several rheumatologic diseases, including granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and systemic lupus erythematosus (SLE) may present with fever, rash, and pulmonary symptomatology.

A history of the patient’s exposures, both environmental and pharmaceutical, should be obtained. More information regarding his immunization history, rash characteristics (distribution and nature of the lesions), and other salient exam findings such as organomegaly and joint abnormalities will be helpful.

Fever reached a maximum of 103° Fahrenheit and was associated with chills but not rigors. There were several fever spikes daily, relieved completely with antipyretics. The patient’s dyspnea was predominantly noted on exertion, nonpleuritic, not temporally related to cough, and progressively worsening over three days. The skin lesions were first noticed on his trunk and were described as reddish, flat, and pinpoint size. However, the rash spread to the face and extremities sparing the palms and soles. There was no bleeding, nausea, vomiting, abdominal pain, change in bowel habits, dysuria, headache, photophobia, neck stiffness, or joint pain.

The patient reported no significant past medical history, took no medications, and had no recent travel outside of Delhi, India in the past year. He was married and monogamous. He had no pets nor did he report any contact with animals. He did not use tobacco, alcohol, or illicit substances. He did not remember being bitten by an insect. He worked as a software engineer. There was no history of similar illness in the patient’s family or at his workplace. He had no history of recent blood transfusion or immunization (including MMR and Tdap).