Photo Quiz

Rash and Fever in a College Student IGOR MELNYCHUK, MD, and WENDY BUSBY, MD, FRACP, University of Otago, Dunedin School of Medicine, Dunedin, New Zealand

The editors of AFP wel- A 21-year-old female college student pre- come submissions for sented to the hospital with rash and high Photo Quiz. Guidelines for preparing and submitting fever. Severe arthralgias and a nonpruritic a Photo Quiz manuscript rash appeared on her lower extremities can be found in the (Figure 1) shortly after the pharyngitis devel- Authors’ Guide at http:// oped. The rash migrated to her chest and www.aafp.org/afp/ photoquizinfo. To be con- head (Figure 2) a few days later. sidered for publication, submissions must meet Question these guidelines. E-mail Figure 1. Based on the patient’s history and physical submissions to afpphoto@ aafp.org. Contributing edi- examination, which one of the following is tor for Photo Quiz is John the most likely diagnosis? E. Delzell, Jr., MD, MSPH. ❏ A. Disseminated tinea corporis. A collection of Photo Quiz- ❏ B. Erythema marginatum. zes published in AFP is ❏ C. Erythema migrans. available at http://www. aafp.org/afp/photoquiz. ❏ D. Erythema multiforme. ❏ E. Erythema nodosum.

See the following page for discussion.

Figure 2.

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Discussion alopecia. Lesions have central clearing The correct answer is B: erythema margin- and slightly raised borders, and are often atum. Erythema marginatum is an evanes- pruritic. cent, nonpruritic rash that typically occurs Erythema migrans has a bull’s-eye on the trunk and extremities, but does not appearance and is a sign of Lyme disease. usually affect the face.1 The patient’s throat Like erythema marginatum, erythema culture was positive for Streptococcus pyo- migrans lesions have central clearing, but genes, and her antistreptolysin O titers were usually expand rather than migrate. Ery- elevated. The rash and arthralgias resolved thema migrans lesions typically have central within a few days of treatment with high- erythema and necrosis. dose aspirin and penicillin. Erythema multiforme is a maculopapular Erythema marginatum occurs in patients rash that is usually located on the palms who have rheumatic fever, and it is a major and feet, although it can have generalized part of the Jones criteria for the diagnosis spreading. It can result from a drug reaction of rheumatic fever. Rheumatic fever can (e.g., sulfa, phenytoin [Dilantin], penicil- cause rheumatic heart disease and requires lins) or from viral and bacterial infections. prompt diagnosis and treatment.2 Erythema multiforme can have a bull’s-eye Tinea corporis (ringworm) does not appearance, but it is usually pruritic and disseminate and is not associated with blanches away slowly. any systemic signs of infection. The rash Erythema nodosum leads to erythema- typically has a fine scale and may cause tous macules that are often painful. The rash most commonly occurs on the shins. There is usually no central clearing. Summary Table Address correspondence to Igor Melnychuk, MD, at [email protected]. Reprints are not available from Condition Characteristics the authors.

Tinea corporis Ringworm lesions with central clearing and Author disclosure: No relevant financial affiliations to slightly raised borders; often pruritic disclose. Erythema marginatum Evanescent, nonpruritic rash usually on the trunk and extremities; occurs with rheumatic fever REFERENCES

Erythema migrans Bull’s-eye appearance; central erythema and 1. Nonsuppurative poststreptococcal sequelae:​ rheumatic necrosis; expands rather than migrates fever and glomerulonephritis. In:​ Mandell GL, Ben- Erythema multiforme Maculopapular rash usually on the palms and nett JE, Dolin R, eds. Principles and Practice of Infec- feet; often pruritic and blanches away slowly tious Diseases. 6th ed. Edinburgh, Scotland:​ Elsevier Churchill Livingstone;​ 2005:​2380-2392. Erythema nodosum Erythematous macules usually on the shins; no central clearing; often painful 2. Ferrieri P;​ Jones Criteria Working Group. Proceedings of the Jones criteria workshop. Circulation. 2002;​ 106(19):​2521-2523. ■

698 American Family Physician www.aafp.org/afp Volume 84, Number 6 ◆ September 15, 2011