Bacterial
The diagnosis of typhoid fever comes to mind off the bat given the region and the economically disadvantaged disposition of the patient. The dermatological manifestations seen are well explained by this diagnosis classically described in the literature as “rose spots”, though they are known to be difficult to see in people with darker skin tones [1]. However, the classic illness caused by Salmonella typhi does not usually cause diarrhea until 1 to 3 weeks after the febrile phase of the illness. Enteric fever casuesed by paratyphi species could be a possible explanation for the presentation. Rickettsial, caused by Rickettsia conorii, Orientia tsutsugamushi and Rickettsia typhi, diseases remain a not uncommon cause of febrile illnesses in the region, with some reports of their prevalence as high as 15% in the state of Maharashtra [2]. While rash, reported as maculopapular in 4.9% to 98% of febrile patients, was the second most common clinical feature, the classical finding of eschar was less frequently reported in Indian studies (4% to 21.1%), with diarrhea occurring in 22.2% of cases [3]. Given the atypical presentation and the lack of clinical history of a tick bite places rickettsial illness lower on the list of differentials. Leptospirosis commonly transmitted through indirect contact with contaminated water amongst rice farmers as they work their fields during the monsoon season, during which this patient presented to our emergency department, should also be given due consideration. Even as this diagnosis explains several clinical manifestations on first blush, as well as the transaminitis, splenomegaly, and thrombocytopenia which would later be found, on closer examination the lack of subconjuctival suffusion along presence of a rash suggest an alternative diagnosis; The unusual case of “Fort Bragg Fever” caused by L. interrogans had an erythematous rash limited to the pretibial areas [4].