IMAGES IN DERMATOLOGY
Parwathi “Uma” Paniker, MD
Rare Red Rash
Shahid Hashmi, MD, Arash Heidari, MD, Arthur Jeng, MD
Department of Medicine, Division of Infectious Diseases, Olive View-UCLA Medical Center, Sylmar, Calif.
PRESENTATION
Strolling through a farmers’ market can offer a pleasant way
to spend an afternoon, but you may pick up more than a few
fresh vegetables. Our patient’s symptoms began with a
nonpruritic rash on his left shin, 4 weeks prior to presenta-
tion. This seemingly harmless skin eruption quickly spread
to bilateral lower and upper extremities, trunk, and abdo-
men. A few days after the rash appeared, he developed
fevers and night sweats. Upon presentation, the 34-year-old
previously healthy Hispanic male had a 4-week history of
fevers, night sweats, a 10-pound weight loss, and a wide-
spread rash. Prior to the development of his symptoms, he was
submerged in ocean water during his Jehovah’s Witness bap-
tism ceremony and ate some cheese purchased at an open-air
market. Working in a fast food restaurant, the patient has
regular contact with food, but he denied any medication usage,
animal exposure, insect bites, or recent travel.
ASSESSMENT
On physical exam, the patient appeared diaphoretic and was
slow in answering questions. He had a temperature 38.7°C
(101.7° F), pulse 119 beats/min, respiratory rate 19 breaths/
min, blood pressure 121/63 mm Hg. His physical examina-
tion was significant for a palpable spleen and the dermato-
logic findings of a papulonodular, violet-erythematous rash
on the legs, arms, trunk, and abdomen, but not the palms
and soles (Figures 1 and 2). On the legs, the rash was more
confluent, with pitting edema extending to the knees.
Laboratory results revealed white blood cell count 4.8
10
3
/L (63% neutrophils, 26% lymphocytes, 10% mono-
cytes), hemoglobin 11gm/dL, platelets 140 10
3
/L, ESR
89 mm/hr, aspartate aminotransferase (AST) 104 units/L,
alanine aminotransferase (ALT) 101 units/L, alkaline phos-
phatase 153 units/L, total bilirubin 0.7 mg/dL. Other labo-
ratory tests, including chemistry and urinalysis, were nor-
mal. Serologic tests for HIV, rapid plasma reagin (RPR),
hepatitis B and C, Coccidioides immitis, and anti-nuclear
antibody (ANA) were negative. A transthoracic echocardio-
gram was normal, with no vegetations. The chest radiograph
was normal, and CT of abdomen/pelvis demonstrated mod-
erate hepatomegaly and splenomegaly. Two sets of blood
cultures were drawn on the day of admission.
DIAGNOSIS
The constellation of chronic fevers, mild hepatitis, hepato-
splenomegaly, and maculopapular rash hinted at a several
potential diagnoses. A lengthy list of possible causes for the
patient’s symptoms was investigated:
● Rickettsial disease (Rickettsia typhi or murine typhus,
which is endemic in southern California);
● Coxiella burnetti (Q fever), which can present with the
rash as a consequence of subacute endocarditis;
● Bacterial endocarditis with immune-complex deposition;
● Fungal diseases such as coccidioidomycosis with ery-
thema nodosum;
● Secondary syphilis;
● Typhoid fever with rose spots;
● Viral diseases including primary HIV and enteroviral
infections;
● Vasculitidies.
Many of the above diagnoses were ruled out with the
blood tests and studies previously mentioned. After 3 days,
the admission blood cultures signaled growth, and their
gram stain revealed, unexpectedly, gram-negative coccoba-
cilli that were speciated as Brucella melitensis (B.meliten-
sis). Brucella serologies were positive at titers IgG1:2560
and IgM1:160.
Brucellosis is a zoonotic infection caused by Brucella spe-
cies, most commonly B. melitensis, found in sheep and goat,
followed by B. abortis (found in cattle), and least commonly B.
suis (swine) and B. canis (dogs).
1
Brucella is a small gram-
negative, intracellular coccobacillus that is oxidase- and cata-
lase-positive. This infection is commonly seen in Mediterra-
nean, Asian, and Latin American countries.
2
In the US, it
primarily occurs in Texas and California, where unpasteurized
goat milk products imported from Mexico are its main source.
3
Requests for reprints should be addressed to Arthur Jeng, MD, Division
of Infectious Diseases, Olive View UCLA Medical Center, UCLA School
of Medicine, 14445 Olive View Dr. 2B182, Sylmar, CA 91342.
E-mail address: artjeng@ucla.edu
0002-9343/$ -see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjmed.2008.07.005