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Dengue rash: white islands in a sea of red
  1. Hiroki Matsuura1,
  2. Masayuki Kishida1,2,
  3. Yumi Nakata1,
  4. Kahori Hirata1,
  5. Erika Sasaki2,
  6. Yoshihiko Kiura1
  1. 1 General Internal Medicine, Okayama City Hospital, Okayama, Japan
  2. 2 Endocrinology, Okayama City Hospital, Okayama, Japan
  1. Correspondence to Dr Hiroki Matsuura, General Internal Medicine, Okayama City Hospital, Okayama 700-0962, Japan; superonewex0506{at}

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A 36-year-old Japanese woman presented to our emergency department with a 2-day history of fever, headache, eye pain, arthralgia and poor appetite after returning from Thailand. She had been sightseeing in Phuket, as island in Thailand. At initial presentation, her body temperature was 38.9°C. Laboratory examination results revealed a slightly elevated C reactive protein level of 0.57 mg/dL (range: 0–10 mg/dL), normal white blood cell count of 4.16 ×10ˆ9/L and normal platelet count of 233 ×10ˆ9/L. The result of the rapid diagnostic kit for the dengue virus (DENV) was positive for DENV non-structural protein-1 antigen. The result of the serum dengue PCR assay for detection and serotype identification was positive for DENV-1. Based on clinical findings, we made a diagnosis of dengue fever. Her platelet counts progressively decreased from 233 ×10ˆ9/L at admission to 94 ×10ˆ9/L, and her haematocrit increased to 43.8%. She was treated with Ringer’s lactate solution. Three days after defervescence, skin examination showed a characteristic generalised confluent petechial rash with multiple small round islets of normal skin (ie, white islands in a sea of red; figure 1). Her symptoms gradually improved; she was discharged after complete recovery. Dengue fever is the most prevalent arthropod-transmitted viral infection in many tropical and subtropical regions, including Central America, South America, Southeast Asia, South Central Asia and Sub-Saharan Africa.1 It is a viral infection caused by four types of DENV belonging to the genus Flavivirus. DENVs are transmitted to humans by infected mosquitoes, mainly Aedes aegypti and Aedes albopictus.2 A previous study reported that the overall mortality rate for dengue fever of 3.6%.3 The differential diagnosis of dengue fever is chikungunya fever, West Nile fever, Zika virus disease, malaria, influenza, measles, rubella and scarlet fever. Thus, characteristic skin rash is a useful clue to narrow the differential diagnosis in travellers, students, migrant workers and refugees with fever and rash. Because of globalisation, international travellers may spread dengue fever within their native country on return. Although, the last reported domestic infection of dengue fever in Japan was in 1945, an outbreak of dengue fever occurred in 2014.4 Early detection of infectious dengue patients is important to facilitate appropriate management and treatment, and prevent local transmission in areas where vector mosquitoes are present and active. Thus, clinicians should emphasise the prevention of mosquito bites and avoidance of exposure to mosquito habitats for travellers to mosquito-borne disease endemic area.

Figure 1

Skin examination revealed a characteristic generalised confluent petechial rash with multiple small round islets of normal skin.


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  • Contributors HM contributed to write manuscript, discussion and patient care. All coauthors also contributed to discussion and patient care.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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