Thursday, December 22, 2016

Erythema Marginatum

IMAGES IN CLINICAL MEDICINE

Acute Rheumatic Fever with Erythema Marginatum

Makoto Saito, M.D.Shuji Hatakeyama, M.D., Ph.D.
N Engl J Med 2016; 375:2480December 22, 2016DOI: 10.1056/NEJMicm1601782
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A previously healthy 36-year-old man presented with a 1-month history of fever and pain in both shoulders and knees, which had been preceded by a sore throat 2 weeks before the onset of fever. Laboratory studies were notable for a white-cell count of 13,800 per cubic millimeter (85% neutrophils), a C-reactive protein level of 26 mg per deciliter (reference value, ≤0.3), and an antistreptolysin O titer of 1478 IU per milliliter (reference value, <241 10="" a="" abated="" abdomen="" administration="" after="" and="" anel="" annular="" antiinflammatory="" aortic="" appeared="" arthralgias="" before="" black="" course="" days="" diameter="" dots="" drug.="" echocardiography="" faded="" fever="" few="" forearm="" his="" hours="" href="http://www.nejm.org/doi/suppl/10.1056/NEJMicm1601782/suppl_file/nejmicm1601782_appendix.pdf" ig.="" in="" indicate="" ink="" later="" lesion="" lesions="" limbs="" macules="" migrated="" mild="" nbsp="" new="" nonpruritic="" nonsteroidal="" of="" on="" one="" over="" painless="" photograph="" rash="" red="" regurgitation.="" revealed="" right="" s1="" shows="" style="border: 0px; color: #006892; font-size: 13.008px; font-style: inherit; font-weight: inherit; margin: 0px; outline: 0px; padding: 0px; text-decoration: none; vertical-align: baseline;" taken="" that="" the="" then="" time="" transthoracic="" upper="" was="" week="" while="" within="">Supplementary Appendix
, available at NEJM.org). Skin biopsy revealed perivascular infiltration of lymphocytes and neutrophils in the dermis (Panel B, hematoxylin and eosin). Acute rheumatic fever with erythema marginatum was diagnosed. Erythema marginatum, an evanescent nonpruritic macular rash, is one of the major Jones criteria for the diagnosis of acute rheumatic fever. The patient began taking amoxicillin for secondary prophylaxis of rheumatic heart disease. The rash disappeared completely 4 months after presentation, and the antistreptolysin O titer decreased to 246 IU per milliliter 12 months after presentation.
Makoto Saito, M.D.
University of Tokyo Hospital, Tokyo, Japan
Shuji Hatakeyama, M.D., Ph.D.
Jichi Medical University, Tochigi, Japan
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