A 20-Year-Old Man With a Dark, Burning Rash

Christian Beebe, MD, MBA

Disclosures

August 13, 2015

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 20-year-old active-duty male soldier presents to the emergency department of a military hospital with a 3-day history of a dark-red "burning rash." The rash started at his sock line and, over the course of the past 2 days, has spread proximally up his thighs. It is not present on his abdomen or back, but it has spread to his hands over the past day. The patient also developed a sore throat and a scratchy voice the day before presentation, without odynophagia.

The patient had been in the North Carolina woods as part of his infantry training. He reports having spent more than 20 hours per day for the past several days in a foxhole (a hole in the ground that soldiers use for protection). The patient reports fatigue only related to his level of activity and lack of sleep during training.

The patient is not taking any medications, has no allergies, and has smoked 5-10 cigarettes daily for the past year. He also reports drinking approximately five to 10 beers with his comrades once or twice per month before starting his training.

The patient noted some right-ankle swelling and pain that started after a 12.43-mile field hike with a 60-lb rucksack on his back. The pain and swelling began 1 month before admission and has worsened in the past few days.

He has had no pruritus, fevers, chills, abdominal pain, diarrhea, changes in urine color, or dysuria, as well as no new sexual contacts and no recent animal or insect bites. No one else in his military unit has reported similar skin findings.

The patient had a minor motorcycle accident 18 months ago, with a right-leg laceration that required suture repair. He has no significant family history.

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