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Isles of white in a sea of red: an underdiagnosed entity?
  1. Gaurav Gautam,
  2. Daisy Khera and
  3. Kuldeep Singh
  1. Pediatrics, All India Institute of Medical Sciences, Jodhpur, Jodhpur, India
  1. Correspondence to Dr Daisy Khera; pushpinderdaisy{at}gmail.com

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Description

A 6-year-old girl was admitted to our hospital with complaints of acute onset of fever 5 days back, followed by abdominal pain, vomiting and generalised rash 3 days later. On examination, the vitals were stable. There was generalised non blanchable erythema with few patchy areas of normal skin scattered all over the body as shown in figure 1.

Figure 1

Legend characteristic generalised erythematous rash giving the appearance of red sea with multiple small round white islands of normal skin.

Her dengue NS-1 antigen, done on day 3 of illness (on out-patient basis), was positive. She reported again 2 days later with warning signs and was admitted and managed as per protocol1 with maximum hematocrit of 45% at the time of admission and lowest platelet count of 52×109/L on day 2 of admission. She remained afebrile throughout her hospital stay. Abdominal pain and vomiting subsided on day 2 of admission. But the generalised rash persisted which later on became itchy. Itching was controlled by anti-histamines.

She was discharged after 4 days. Rash was persisting at the time of discharge with minimal change since admission and gradually subsided within 3 days after discharge.

Dengue infection can sometimes lead to a peculiar type of confluent erythematous or petechial rash, which does not blanch on pressure, with small areas of normal skin termed as ‘isles of white in a sea of red’.2 These types of rashes appear during periods of defervescence and gradually fade over 1 week. These are thought to be due to immune response to the virus and are usually asymptomatic with pruritus being reported in a minority of patients with prevalence of 16% and 27.6% reported in two studies.3

Learning points

  • Fever with rash has many varied differentials. The characteristic appearance of rash is a useful clue to diagnose dengue.

  • The characteristic appearance is due to increased capillary permeability and fluid leakage in dengue and is a marker of dengue defervescence.

  • Due to the growing number of people travelling to and from endemic areas, dengue is becoming an emerging disease in industrialised countries that are popular destinations for tourists. Therefore, it is important to learn to identify its characteristic rash.

References

Footnotes

  • Twitter @drkuldeep

  • Contributors GG made substantial contributions to the conception and drafting of the work and revising it critically for important intellectual content and finally approved the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. DK made substantial contributions to the conception and drafting of the work and revising it critically for important intellectual content and finally approved the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. KS made substantial contributions to the drafting of the work and revising it critically for important intellectual content and finally approved the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Next of kin consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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