Tropical/Infectoparasitary Dermatology
Exanthematic dengue fever mimicking rubella
Dario Palhares
Universidade de Brasília, Brasília, DF, Brazil
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"tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "85" "paginaFinal" => "87" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 853 "Ancho" => 2920 "Tamanyo" => 174812 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Confluent rash presented by the patient nine days after the onset of respiratory symptoms. 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Overview of the rash.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Dengue fever is a systemic infectious disease transmitted by mosquitoes of the genus Aedes, caused by the dengue virus, which presents with five serotypes (serotypes 1 to 4 are observed worldwide and serotype 5 has been identified in India).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Infection by one of the serotypes does not confer immunity against the others.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Risk factors for the development of severe dengue conditions include: previous episode of dengue, advanced age, and presence of comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 42-year-old male patient, previously vaccinated for hepatitis A and B, had had first dengue infection 15 years earlier, with a febrile presentation and positive IgM serology. He reported that two days before presenting to this service, small papules appeared on the trunk, but that morning his body presented a rubelliform rash (<a class="elsevierStyleCrossRef" href="#fig0005">Figs. 1</a>–3) affecting from neck to knees and elbows, but sparing the face. He complained of asthenia but denied fever. The general physical examination showed no abnormalities other than the rash, not even palpable nodes. Complementary exams on arrival were as follows: blood count with hemoglobin, 15.4 g/dL; platelets, 170,000/mL; leukocytes, 4,020 mL (segmented 39%, eosinophils 3%, basophils 1%, lymphocytes 35%, monocytes 22%); IgM, IgG, and NS1 were negative for dengue fever; transaminases, bilirubin, and muscle enzymes were normal. The rash progressed two more days, affecting his palms and soles. The patient reported some diarrheal episodes, and denied fever. On the sixth day of evolution, the rash started to disappear, and the exams showed the following: hemogram with hemoglobin, 15.8 g/dL; platelets, 148,000/mL; and leukocytes, 4,910 mL (segmented 20%, eosinophils 5%, lymphocytes 59%, atypical lymphocytes 6%, monocytes 10%). Serologies: immune pattern for toxoplasmosis, cytomegalovirus, measles, herpes simplex, and Epstein-Barr virus. Non-reactive for HIV, syphilis, Zika virus, chikungunya, borreliosis, and rubella. IgG and IgM were positive for dengue fever. Total IgE was 713.8 IU/mL. The patient recovered completely and was revaccinated for rubella.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">This case is unusual because it was a second episode of dengue, with afebrile presentation and mimicking rubella, with cranio-caudal progression of rubelliform rash. Over the years, IgG titers against dengue fever tend to fall and eventually become negative, and lower IgG titers are a protective factor against severe forms of dengue.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, in the case of a second infection, there is an anamnestic response, with early onset of IgG, and it is possible that an eventual third episode of dengue in this patient will be more severe. The NS1 antigen has a sensitivity of approximately 85% and tends to be lower in second episodes of dengue, <span class="elsevierStyleItalic">i.e</span>., in clinical practice a relatively considerable proportion of patients will not be diagnosed in the initial stage of the disease.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is possible that the patient's allergies have influenced the clinical presentation, with a rash that is not the classically described for dengue.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Since the rash was spontaneously and quickly resolved, biopsies were not performed, as would be recommended if the rash became chronic. However, in this case, the blood count proved to be useful for clinical management, as it showed a typically viral pattern, even regarding atypical lymphocytes related to various diseases, including dengue fever and rubella.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> In conclusion, the relationship between parasites and hosts is complex, and dengue should be part of the differential diagnosis of rashes, even though the patient does not present classic symptoms, such as fever or orbital pain. Furthermore, in the emergency room setting, the complete blood count, an exam usually ready in a few hours, can assist in the clinical decision.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors’ contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Dario Palhares: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1461419" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1331603" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Financial support" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-07-05" "fechaAceptado" => "2020-06-04" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1331603" "palabras" => array:4 [ 0 => "Dengue" 1 => "Immunoglobulin E" 2 => "Immunoglobulin G" 3 => "Serology" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The authors present a case of dengue fever mimicking rubella. Male patient, in the second episode of dengue fever, presented afebrile, with diffuse morbilliform rash and craniocaudal progression, having subsequently affected his palms and soles. On the third day of clinical evolution, serologies did not indicate IgM, IgG, or NS1, but on the sixth day of evolution, IgM and IgG were reactive for dengue fever. Previous episodes of dengue are a risk factor for the development of more severe conditions, but this was atypical because the patient was afebrile and had a rubelliform rash. The case also illustrates an early IgG anamnestic response, as it was a reinfection.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Palhares D. Exanthematic dengue fever mimicking rubella. An Bras Dermatol. 2021;96:88–90.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Pivate Clinic, Brasília, DF, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 526 "Ancho" => 905 "Tamanyo" => 63122 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Detail of the rash. Overview of the rash.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1631 "Ancho" => 905 "Tamanyo" => 208383 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Overview of the rash. Rubelliform rash, on the third day of clinical evolution. The right axillary region was spared.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1661 "Ancho" => 905 "Tamanyo" => 131702 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Third day of clinical evolution, left side of the body: the axillary region was affected.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Discovery of fifth serotype of dengue virus (DENV-5). 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 28 | 14 | 42 |
| 2024 October | 163 | 83 | 246 |
| 2024 September | 220 | 96 | 316 |
| 2024 August | 283 | 104 | 387 |
| 2024 July | 293 | 113 | 406 |
| 2024 June | 210 | 82 | 292 |
| 2024 May | 152 | 76 | 228 |
| 2024 April | 206 | 85 | 291 |
| 2024 March | 216 | 78 | 294 |
| 2024 February | 181 | 81 | 262 |
| 2024 January | 135 | 69 | 204 |
| 2023 December | 145 | 72 | 217 |
| 2023 November | 189 | 78 | 267 |
| 2023 October | 155 | 77 | 232 |
| 2023 September | 93 | 78 | 171 |
| 2023 August | 65 | 42 | 107 |
| 2023 July | 65 | 54 | 119 |
| 2023 June | 75 | 53 | 128 |
| 2023 May | 65 | 38 | 103 |
| 2023 April | 61 | 19 | 80 |
| 2023 March | 69 | 54 | 123 |
| 2023 February | 48 | 34 | 82 |
| 2023 January | 60 | 49 | 109 |
| 2022 December | 77 | 40 | 117 |
| 2022 November | 90 | 54 | 144 |
| 2022 October | 82 | 53 | 135 |
| 2022 September | 59 | 78 | 137 |
| 2022 August | 59 | 50 | 109 |
| 2022 July | 73 | 54 | 127 |
| 2022 June | 54 | 56 | 110 |
| 2022 May | 39 | 57 | 96 |
| 2022 April | 71 | 55 | 126 |
| 2022 March | 54 | 76 | 130 |
| 2022 February | 39 | 35 | 74 |
| 2022 January | 75 | 80 | 155 |
| 2021 December | 52 | 63 | 115 |
| 2021 November | 55 | 81 | 136 |
| 2021 October | 63 | 86 | 149 |
| 2021 September | 64 | 55 | 119 |
| 2021 August | 71 | 68 | 139 |
| 2021 July | 65 | 58 | 123 |
| 2021 June | 40 | 70 | 110 |
| 2021 May | 103 | 129 | 232 |
| 2021 April | 206 | 337 | 543 |
| 2021 March | 166 | 85 | 251 |
| 2021 February | 56 | 31 | 87 |
| 2021 January | 37 | 17 | 54 |
| 2020 December | 11 | 8 | 19 |
| 2020 November | 2 | 2 | 4 |
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