A 30-Year-Old With a Full-Body Rash, Vomiting, and Confusion

Andrea Bianchin, MD; Moreno Agostini, MD


September 22, 2021

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 that you would like to suggest for a future Case Challenge, please contact us.


A 30-year-old woman presents to the emergency department with malaise, diffuse myalgia, and a rash that has spread all over her body (Figures 1 and 2).

Figure 1.

Figure 2.

Her symptoms began the day before presentation and initially improved with ibuprofen. Her boyfriend, who has accompanied her to the emergency department, adds that she has been vomiting, has appeared to be in pain with movement, and has had intermittent confusion during the night.

The patient has developed a headache of moderate intensity that is diffuse, radiates to her neck, and worsens with movement. She does not have any photophobia or dizziness, and she has not experienced any seizures. She denies having subjective fever, abdominal pain, hematemesis, or diarrhea. She has not had any urinary symptoms or low back pain. She denies having cough or shortness of breath.

The patient's medical history is remarkable only for trauma that occurred 3 months ago and resulted in rib fractures and blunt abdominal trauma. At that time, she underwent exploratory laparotomy, with suture repair of liver lacerations and a right kidney laceration; she has been doing well since then. The patient does not have any chronic medical conditions and does not take any regular medications. She smokes cigarettes but denies heavy alcohol use or illicit drug use.


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