A non-travel related rash in a traveler.

A 45-year-old man was admitted for investigation of a symmetric lower limb rash associated with recurrent fever for two weeks following a hiking trip in Italy and Greece. He was treated for sepsis secondary to lower limb cellulitis with no clinical improvement and subsequently diagnosed with Streptococcus gallolyticus endocarditis mediating an infectious vasculitis.

Case report

A 45-year-old man presented with a symmetric rash over his lower legs associated with recurrent fever following a hiking trip in southern Europe. He traveled to Rome, Florence, and Athens and hiked in the Calabria region of south Italy for 10 days. On his return flight he developed swelling and erythema of his ankles spreading proximally. He described discrete red lesions that spread to the arms, torso and back. The patient did not recall any tick bites or being in the vicinity of sick contacts. He denied intravenous drug use or new sexual partners. He denied ever having any dental procedures but was noted to have poor dental hygiene on examination of the oral cavity.

Upon arrival home he experienced recurrent fevers up to 38.9 °C on a daily basis. He was evaluated by his primary care physician who prescribed 7 days of clindamycin for presumed cellulitis with no clinical improvement.

He presented to our emergency department two weeks after his return. The patient was febrile (39.1 °C), tachycardic (116 beats per minute) with signs of mild dehydration. Cardiovascular examination was pertinent for significant bilateral pitting edema of both legs from the dorsa of the feet to the knees. Otherwise heart and lung sounds were unremarkable. There was no murmur. No hepatomegaly or splenomegaly was identified and neurological exam was non-focal. A diffuse purpuric rash was noted predominantly over both legs (Fig. 1). Admission labs showed a leukocytosis 11.4 × 109/L (3.5–10.5 × 109L), lactate 2.7 mmol/L (0.9–1.7 mmol/L) and a normocytic anemia (hemoglobin 9.5 g/dL [13.5–17.5 g/dL], mean corpuscular volume 92.5 fL [81.2–95.1fL]) with 2.7% reticulocytes (0.5–2.5%). He had an erythrocyte sedimentation rate (ESR) of 71 mm/1 h (0–22 mm/1 h) and quantitative serum C-reactive protein level of 98.9 mg/L (<8.0 mg/L). Blood cultures were positive for alpha-hemolytic streptococci. He was treated for sepsis likely secondary to lower limb cellulitis with intravenous vancomycin, cefepime and doxycycline. However he had persistent recurrent fever with progressive worsening of the rash 24 h into his admission.

Fig. 1

Diffuse purpuric rash over both legs.

Human immunodeficiency virus, hepatitis B and C serologies were negative as were assays for Rickettsiae, Brucella, lyme disease, leishmaniasis and Q fever. A transthoracic echocardiogram (TTE) showed a mobile echo density (measuring 8 mm × 1.2 mm) arising from the ventricular surface of the aortic valve. This was confirmed on transesophageal echocardiogram (TEE), and the patient was switched to IV ceftriaxone for treatment of native-valve endocarditis. The rash was deemed to be an infectious vasculitis as a skin manifestation of infective endocarditis. The patient did not have any prior cardiac history, rheumatic fever or recent dental work. Blood cultures were positive for an organism within the Streptococcus gallolyticus group (time to detection of 32 h). He subsequently underwent a screening colonoscopy to rule out colorectal pathology given the association with S. gallolyticus subsp. gallolyticus endocarditis [1]. No macroscopic lesions were identified on colonoscopy.

The patient completed 6 weeks of intravenous ceftriaxone with complete symptomatic resolution Repeat ESR and CRP were back to baseline levels. The patient’s rash manifesting as an infectious vasculitis was the only sign of infective endocarditis. This case highlights the need to refine a differential diagnosis for infectious etiologies based upon their geographic distribution [2]. However, when a standard workup for fever and a rash in a returning traveler is negative, a broader differential diagnosis must be entertained.

Conflict of interest

All authors declare no conflicts of interest.

Funding

None.