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A 22-year-old white man presented to the emergency room with a 4-to 5-day history of fever, chills, myalgias, arthralgias, severe headache, and photophobia. The patient had noted a rash for 3 days that began on the right anterior aspect of his thigh and rapidly spread to involve the rest of his extremities, palms, soles, and trunk. Subsequently, diffuse abdominal pain, anorexia, and diarrhea developed. Postural dizziness occurred on the day of admission.The patient stated that for the 10 days preceding his illness he had worked cutting timber in a wooded area near his home. Although he did not remember being bitten by a tick, he recalled brushing ticks off his clothing.At the time of admission, the patient's supine blood pressure was 96/60 mm Hg, with a resting tachycardia of 140 beats per minute and a temperature of 39.7\s=deg\C.His abdomen was diffusely tender; the tip of his spleen was palpable. A diffuse rash of 3-to 6-mm erythematous maculae was present over the patient's trunk (Fig 1) and extremities, with relative sparing of his face. Petechiae were present on his palms (Fig 2) and soles and were superimposed on the macular rash of his extremities. The physical examination showed otherwise normal findings. Laboratory studies showed the following results: sodium, 122 mmol/L; chloride, 94 mmol/L; bicarbonate, 9 mmol/L; potassium, 3.4 mmol/L; serum urea nitrogen, 5.7 mmol/L; creatine, 100 mhioI/L; glucose, 8.0 mmol/L; hemoglobin, 13.6 g/L; hematocrit, 0.40; leukocytes, 7.8 X 10VL; platelets, 14 X 10VL; prothrombin time, 11.9 seconds; partial thromboplastin time, 29.2 sec¬ onds; fibrinogen, 2.36 g/L (normal, 2.7 to 4.1 g/L); arterial blood gas pH, 7.54; partial pressure of carbon dioxide, 24.8 mm Hg; and partial pressure of oxygen, 91 mm Hg.A skin biopsy specimen was obtained from a petechial lesion. Light microscopic findings are shown in Figs 3 and 4.
A 22-year-old white man presented to the emergency room with a 4-to 5-day history of fever, chills, myalgias, arthralgias, severe headache, and photophobia. The patient had noted a rash for 3 days that began on the right anterior aspect of his thigh and rapidly spread to involve the rest of his extremities, palms, soles, and trunk. Subsequently, diffuse abdominal pain, anorexia, and diarrhea developed. Postural dizziness occurred on the day of admission.The patient stated that for the 10 days preceding his illness he had worked cutting timber in a wooded area near his home. Although he did not remember being bitten by a tick, he recalled brushing ticks off his clothing.At the time of admission, the patient's supine blood pressure was 96/60 mm Hg, with a resting tachycardia of 140 beats per minute and a temperature of 39.7\s=deg\C.His abdomen was diffusely tender; the tip of his spleen was palpable. A diffuse rash of 3-to 6-mm erythematous maculae was present over the patient's trunk (Fig 1) and extremities, with relative sparing of his face. Petechiae were present on his palms (Fig 2) and soles and were superimposed on the macular rash of his extremities. The physical examination showed otherwise normal findings. Laboratory studies showed the following results: sodium, 122 mmol/L; chloride, 94 mmol/L; bicarbonate, 9 mmol/L; potassium, 3.4 mmol/L; serum urea nitrogen, 5.7 mmol/L; creatine, 100 mhioI/L; glucose, 8.0 mmol/L; hemoglobin, 13.6 g/L; hematocrit, 0.40; leukocytes, 7.8 X 10VL; platelets, 14 X 10VL; prothrombin time, 11.9 seconds; partial thromboplastin time, 29.2 sec¬ onds; fibrinogen, 2.36 g/L (normal, 2.7 to 4.1 g/L); arterial blood gas pH, 7.54; partial pressure of carbon dioxide, 24.8 mm Hg; and partial pressure of oxygen, 91 mm Hg.A skin biopsy specimen was obtained from a petechial lesion. Light microscopic findings are shown in Figs 3 and 4.
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