Endgames Case Report

Fever and rash in a returning traveller

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2400 (Published 11 April 2012) Cite this as: BMJ 2012;344:e2400
  1. Neelam Kumar, core medical trainee1,
  2. David J Lewis, professor of infectious diseases2
  1. 1Clinical Infection Unit, St George’s Hospital, London SW17 0QT, UK
  2. 2St George’s Vaccine Institute, St George’s University of London, London, UK
  1. Correspondence to: N Kumar neelamkumar{at}doctors.org.uk

A previously fit and well 26 year old male student of Chinese origin attended the emergency department with a five day history of a febrile illness. He had returned to the United Kingdom from a three week visit to Malaysia and Singapore the day before the illness began. His main symptoms were fever, headache, and nausea. He had also noted a faint widespread rash the day before admission.

On examination his temperature was 39.7°C, his blood pressure was 134/77 mm Hg, and he had a regular heart rate of 75 beats/min. He had a respiratory rate of 14 breaths/min and oxygen saturations of 98% on room air. The only relevant clinical finding was a confluent erythematous macular rash across his chest, back, arms, and legs, with multiple small discrete areas of sparing.

Full blood count showed haemoglobin 163 g/L (120-180), platelets 86×109/L (130-400×109), white cell count (WCC) 3.4×109/L (4.5-11.0×109), neutrophils 1.7×109/L (2.0-7.5×109; 40-75% WCC), lymphocytes 1.4×109/L (1.3-3.5×109; 20-45% WCC), and no eosinophilia (0.04-0.44×109/L; 1-6% WCC). A blood film was negative for malaria parasites and confirmed thrombocytopenia with atypical lymphocytes. Renal function, liver function, and clotting tests were unremarkable and C reactive protein was less than 4 mg/L.


  • 1 What are the most likely clinical diagnosis and important differential diagnosis?

  • 2 How would you confirm this diagnosis?

  • 3 What are the potential complications of this disease?

  • 4 How is this disease treated?

  • 5 How can this disease be prevented?


1 What are the most likely clinical diagnosis and important differential diagnosis?

Short answer

On the basis of the history and clinical picture, the diagnosis is probably dengue infection. Malaria is an important differential diagnosis and should be excluded with serial blood film examination or direct antigen testing (or both).

Long answer

Dengue infection classically presents with an abrupt onset of fever, …

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