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Case of the Month - December 2015

What is the final diagnosis?
K Sinclaire, SASTM

A 36-year-old Dutch female presented with a rash on her left forearm of four days duration. She felt unwell. She and her husband managed a lodge in Nacala, northern Mozambique. Pruritus was a prominent feature of the rash which blistered and showed signs of healing.

There was no travel history. She was a smoker with a 5-10 pack year history, had no allergies or chronic medical conditions and was taking a herbal oral spray for malaria prophylaxis. Her husband mentioned that their pet squirrel had died two weeks previously. Her vaccination status was unknown. There was no history of a tick bite.

She was, at the onset of the rash, seen at a district hospital locally where two rapid malaria antigen tests were both negative. The diagnosis made was that of a bacterial infection; cefaclor and an antihistamine were prescribed.

The day after she went to the clinic she developed severe back and neck pain with headache and diarrhoea. She felt dizzy when standing and developed an arthralgia of her knees. She had episodes of fever for which she took paracetamol. The headache continued to worsen despite the paracetamol.

Question 1: What is the differential diagnosis for this patient with fever, rash, headache and myalgia in remote northern Mozambique?

Continue to Answer 1