A Fever, Then a Papular Eruption: Make a Rash Diagnosis

Nicole P. Huffman, MD


April 06, 2012

Case Presentation: A Woman With Fever, Leukocytosis, and Rash

A 27-year-old white woman presents to the emergency department with a week-long history of fever, cough, myalgia, and sore throat. She became concerned when, after 3 days, she developed a red, bumpy rash on her hands, chest, and neck. The rash was slightly tender and did not improve with application of over-the-counter steroid cream. She also noticed that her eyes had become red and irritated after the onset of the rash.

Physical Examination

Physical examination reveals multiple rosette-like crops of pink, firm pseudovesicular papules and plaques on the dorsal hands (Figures 1 and 2) and neck (Figure 3). Closer inspection shows the mamillated papillary surface change (Figure 4). The patient also has bilateral conjunctival injection and a temperature of 102.1 °F.

Figure 1. Pink pseudovesicular papules on the dorsal hands.

Figure 2. Pink pseudovesicular papules on the dorsal hands.

Figure 3. Pink pseudovesicular plaque on the neck.

Figure 4. Close-up of the mamillated papules on the dorsal hand.

Diagnostic Evaluation

Histopathology. Hematoxylin and eosin stain (Figure 5) reveals irregular epidermal hyperplasia with focal areas of superficial epidermal necrosis, extensive edema of the superficial papillary dermis, and a predominantly superficial nodular infiltrate. The mixed infiltrate is composed of lymphocytes, histiocytes, neutrophils, eosinophils, and nuclear dust (due to karyorrhexis) (Figures 6 and 7). No vasculitis is apparent.

Figure 5: Hematoxylin and eosin stain, low magnification (20x).

Figure 6: Hematoxylin and eosin stain, low magnification (40x).

Figure 7: Hematoxylin and eosin stain, low magnification (40x).

Laboratory studies. A bacterial throat culture is positive for group A Streptococcus pyogenes. Leukocytosis is found on complete blood count.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.