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].