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previously vaccinated for hepatitis A and B&#44; had had first dengue infection 15 years earlier&#44; with a febrile presentation and positive IgM serology&#46; He reported that two days before presenting to this service&#44; small papules appeared on the trunk&#44; but that morning his body presented a rubelliform rash &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>&#8211;3&#41; affecting from neck to knees and elbows&#44; but sparing the face&#46; He complained of asthenia but denied fever&#46; The general physical examination showed no abnormalities other than the rash&#44; not even palpable nodes&#46; Complementary exams on arrival were as follows&#58; blood count with hemoglobin&#44; 15&#46;4&#8239;g&#47;dL&#59; platelets&#44; 170&#44;000&#47;mL&#59; leukocytes&#44; 4&#44;020&#8239;mL &#40;segmented 39&#37;&#44; eosinophils 3&#37;&#44; basophils 1&#37;&#44; lymphocytes 35&#37;&#44; monocytes 22&#37;&#41;&#59; IgM&#44; IgG&#44; and NS1 were negative for dengue fever&#59; transaminases&#44; bilirubin&#44; and muscle enzymes were normal&#46; The rash progressed two more days&#44; affecting his palms and soles&#46; The patient reported some diarrheal episodes&#44; and denied fever&#46; On the sixth day of evolution&#44; the rash started to disappear&#44; and the exams showed the following&#58; hemogram with hemoglobin&#44; 15&#46;8&#8239;g&#47;dL&#59; platelets&#44; 148&#44;000&#47;mL&#59; and leukocytes&#44; 4&#44;910&#8239;mL &#40;segmented 20&#37;&#44; eosinophils 5&#37;&#44; lymphocytes 59&#37;&#44; atypical lymphocytes 6&#37;&#44; monocytes 10&#37;&#41;&#46; Serologies&#58; immune pattern for toxoplasmosis&#44; cytomegalovirus&#44; measles&#44; herpes simplex&#44; and Epstein-Barr virus&#46; Non-reactive for HIV&#44; syphilis&#44; Zika virus&#44; chikungunya&#44; borreliosis&#44; and rubella&#46; IgG and IgM were positive for dengue fever&#46; Total IgE was 713&#46;8 IU&#47;mL&#46; The patient recovered completely and was revaccinated for rubella&#46;</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&#44; with afebrile presentation and mimicking rubella&#44; with cranio-caudal progression of rubelliform rash&#46; Over the years&#44; IgG titers against dengue fever tend to fall and eventually become negative&#44; and lower IgG titers are a protective factor against severe forms of dengue&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; in the case of a second infection&#44; there is an anamnestic response&#44; with early onset of IgG&#44; and it is possible that an eventual third episode of dengue in this patient will be more severe&#46; The NS1 antigen has a sensitivity of approximately 85&#37; and tends to be lower in second episodes of dengue&#44; <span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; in clinical practice a relatively considerable proportion of patients will not be diagnosed in the initial stage of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is possible that the patient&#39;s allergies have influenced the clinical presentation&#44; with a rash that is not the classically described for dengue&#46;<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&#44; biopsies were not performed&#44; as would be recommended if the rash became chronic&#46; However&#44; in this case&#44; the blood count proved to be useful for clinical management&#44; as it showed a typically viral pattern&#44; even regarding atypical lymphocytes related to various diseases&#44; including dengue fever and rubella&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> In conclusion&#44; the relationship between parasites and hosts is complex&#44; and dengue should be part of the differential diagnosis of rashes&#44; even though the patient does not present classic symptoms&#44; such as fever or orbital pain&#46; Furthermore&#44; in the emergency room setting&#44; the complete blood count&#44; an exam usually ready in a few hours&#44; can assist in the clinical decision&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Dario Palhares&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; critical review of the manuscript&#46;</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&#46;</p></span></span>"
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Tropical/Infectoparasitary Dermatology
Exanthematic dengue fever mimicking rubella
Dario Palhares
Universidade de Brasília, Brasília, DF, Brazil
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previously vaccinated for hepatitis A and B&#44; had had first dengue infection 15 years earlier&#44; with a febrile presentation and positive IgM serology&#46; He reported that two days before presenting to this service&#44; small papules appeared on the trunk&#44; but that morning his body presented a rubelliform rash &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>&#8211;3&#41; affecting from neck to knees and elbows&#44; but sparing the face&#46; He complained of asthenia but denied fever&#46; The general physical examination showed no abnormalities other than the rash&#44; not even palpable nodes&#46; Complementary exams on arrival were as follows&#58; blood count with hemoglobin&#44; 15&#46;4&#8239;g&#47;dL&#59; platelets&#44; 170&#44;000&#47;mL&#59; leukocytes&#44; 4&#44;020&#8239;mL &#40;segmented 39&#37;&#44; eosinophils 3&#37;&#44; basophils 1&#37;&#44; lymphocytes 35&#37;&#44; monocytes 22&#37;&#41;&#59; IgM&#44; IgG&#44; and NS1 were negative for dengue fever&#59; transaminases&#44; bilirubin&#44; and muscle enzymes were normal&#46; The rash progressed two more days&#44; affecting his palms and soles&#46; The patient reported some diarrheal episodes&#44; and denied fever&#46; On the sixth day of evolution&#44; the rash started to disappear&#44; and the exams showed the following&#58; hemogram with hemoglobin&#44; 15&#46;8&#8239;g&#47;dL&#59; platelets&#44; 148&#44;000&#47;mL&#59; and leukocytes&#44; 4&#44;910&#8239;mL &#40;segmented 20&#37;&#44; eosinophils 5&#37;&#44; lymphocytes 59&#37;&#44; atypical lymphocytes 6&#37;&#44; monocytes 10&#37;&#41;&#46; Serologies&#58; immune pattern for toxoplasmosis&#44; cytomegalovirus&#44; measles&#44; herpes simplex&#44; and Epstein-Barr virus&#46; Non-reactive for HIV&#44; syphilis&#44; Zika virus&#44; chikungunya&#44; borreliosis&#44; and rubella&#46; IgG and IgM were positive for dengue fever&#46; Total IgE was 713&#46;8 IU&#47;mL&#46; The patient recovered completely and was revaccinated for rubella&#46;</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&#44; with afebrile presentation and mimicking rubella&#44; with cranio-caudal progression of rubelliform rash&#46; Over the years&#44; IgG titers against dengue fever tend to fall and eventually become negative&#44; and lower IgG titers are a protective factor against severe forms of dengue&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; in the case of a second infection&#44; there is an anamnestic response&#44; with early onset of IgG&#44; and it is possible that an eventual third episode of dengue in this patient will be more severe&#46; The NS1 antigen has a sensitivity of approximately 85&#37; and tends to be lower in second episodes of dengue&#44; <span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; in clinical practice a relatively considerable proportion of patients will not be diagnosed in the initial stage of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is possible that the patient&#39;s allergies have influenced the clinical presentation&#44; with a rash that is not the classically described for dengue&#46;<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&#44; biopsies were not performed&#44; as would be recommended if the rash became chronic&#46; However&#44; in this case&#44; the blood count proved to be useful for clinical management&#44; as it showed a typically viral pattern&#44; even regarding atypical lymphocytes related to various diseases&#44; including dengue fever and rubella&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> In conclusion&#44; the relationship between parasites and hosts is complex&#44; and dengue should be part of the differential diagnosis of rashes&#44; even though the patient does not present classic symptoms&#44; such as fever or orbital pain&#46; Furthermore&#44; in the emergency room setting&#44; the complete blood count&#44; an exam usually ready in a few hours&#44; can assist in the clinical decision&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors&#8217; contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">Dario Palhares&#58; Approval of the final version of the manuscript&#59; design and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; critical review of the literature&#59; critical review of the manuscript&#46;</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&#46;</p></span></span>"
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