1. Case Presentation M.Haghighi MD

2. A woman in her thirties was well until approximately 3 days before presentation in mid-autumn, when fevers up to 103°F (39.4°C) developed, associated with a sore throat and malaise. A woman in her thirties was well until approximately 3 days before presentation in mid-autumn, when fevers up to 103°F (39.4°C) developed, associated with a sore throat and malaise.

3. She took ibuprofen for her symptoms. On the day of presentation, she awoke with a rash over her face, scalp, trunk, and proximal extremities. She took ibuprofen for her symptoms. On the day of presentation, she awoke with a rash over her face, scalp, trunk, and proximal extremities.

4. The lesions were pruritic and tender, and associated with headache and nausea. There was no cough, dysuria, vaginal discharge, or chest, abdomen, or joint pain. The lesions were pruritic and tender, and associated with headache and nausea. There was no cough, dysuria, vaginal discharge, or chest, abdomen, or joint pain.

5. Past medical history /Allergies She reported having had chickenpox as a child and was up-to-date on her immunizations. She reported having had chickenpox as a child and was up-to-date on her immunizations.

6. Medications She had taken ibuprofen for her symptoms, as above. She had taken ibuprofen for her symptoms, as above.

7. Epidemiological History She worked in a healthcare setting, and had no pets or known sick contacts. She traveled intermittently to a wooded area in Northern New England to visit relatives. She worked in a healthcare setting, and had no pets or known sick contacts. She traveled intermittently to a wooded area in Northern New England to visit relatives.

8. There was no history of any unusual skin contacts, or tick or other insect bites. She did not smoke tobacco, drink alcohol, or use illicit drugs. There was no history of any unusual skin contacts, or tick or other insect bites. She did not smoke tobacco, drink alcohol, or use illicit drugs.

9. Physical Examination The patient appeared fatigued and uncomfortable. The temperature was 96.6°F (35.9°C), blood pressure 133/77 mm Hg, pulse 96 beats per minute, and respirations 20 breaths per minute, with an oxygen saturation of 97% while breathing ambient air. The patient appeared fatigued and uncomfortable. The temperature was 96.6°F (35.9°C), blood pressure 133/77 mm Hg, pulse 96 beats per minute, and respirations 20 breaths per minute, with an oxygen saturation of 97% while breathing ambient air.

10. There were numerous discrete, tender, erythematous macules, less than 1 centimeter in diameter with a 1-to-3 millimeter pustular center, on the face, scalp, chest, back, inner thighs, and arms, and one lesion on her palm. There were numerous discrete, tender, erythematous macules, less than 1 centimeter in diameter with a 1-to-3 millimeter pustular center, on the face, scalp, chest, back, inner thighs, and arms, and one lesion on her palm.

13. The physical examination was otherwise normal. The physical examination was otherwise normal.

14. Studies The white blood cell count was 6,300 cells/mm ³, with 35% neutrophils, 35% lymphocytes, 21% atypical lymphocytes, 6% monocytes, 2% eosinophils, and 1% basophils. The white blood cell count was 6,300 cells/mm ³, with 35% neutrophils, 35% lymphocytes, 21% atypical lymphocytes, 6% monocytes, 2% eosinophils, and 1% basophils.

17. She felt worse the following day, with increasing headache and skin lesions. On examination, the temperature was normal; the neck was supple, and examination of the skin revealed approximately 30 pustules on an erythematous base. The remainder of the examination was unchanged from the previous day. She was admitted to the hospital. She felt worse the following day, with increasing headache and skin lesions. On examination, the temperature was normal; the neck was supple, and examination of the skin revealed approximately 30 pustules on an erythematous base. The remainder of the examination was unchanged from the previous day. She was admitted to the hospital.

18. Additional test results included an alkaline phosphatase of 154 U/L (reference range 30-100 U/L), aspartate aminotransferase 42 U/L (reference range 9-32 U/L), alanine aminotransferase 47 U/L (reference range 7-30 U/L), and total bilirubin 0.3 mg/dl. Additional test results included an alkaline phosphatase of 154 U/L (reference range 30-100 U/L), aspartate aminotransferase 42 U/L (reference range 9-32 U/L), alanine aminotransferase 47 U/L (reference range 7-30 U/L), and total bilirubin 0.3 mg/dl.

19. A lumbar puncture was performed, and analysis of the cerebrospinal fluid showed no white blood cells and normal levels of glucose and protein. A lumbar puncture was performed, and analysis of the cerebrospinal fluid showed no white blood cells and normal levels of glucose and protein.

20. A chest radiograph and computed tomography of the brain were also normal. An ultrasound of the abdomen showed diffuse fatty infiltration of the liver and the spleen size was normal. A chest radiograph and computed tomography of the brain were also normal. An ultrasound of the abdomen showed diffuse fatty infiltration of the liver and the spleen size was normal.

21. The patient was seen by the dermatology service and a skin biopsy was performed. The patient was seen by the dermatology service and a skin biopsy was performed.

22. Over the next two days, some lesions evolved to become crusted with a central eschar. Over the next two days, some lesions evolved to become crusted with a central eschar.