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Fever and rash from Timor: where have you been and when?

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Clinical record

A 61-year-old American aid worker was transferred to Royal Darwin Hospital from Timor-Leste with fever and rash. He had worked in Timor for 1 year and was in good health apart from an episode of falciparum malaria treated 9 months previously. He described headache, myalgia and fatigue for 7 days, and 6 days of fever and chills. On Day 2 of illness, he attended a Timorese clinic where an unidentified blood test was reported positive for falciparum malaria. Despite initial treatment with sulfadoxine–pyrimethamine and 3 days of atovaquone–proguanil, his fever and chills persisted. After a further positive test result for falciparum malaria at the same laboratory, he attended a referral clinic on the same day, where thick film blood examination and a histidine-rich protein 2 antigen test were negative for malaria. He was noted to have an erythematous truncal rash and switched to artemether–lumefantrine. Because of ongoing fever, he was evacuated to Australia with provisional diagnoses of malaria or, given the rash, dengue fever.

On arrival at our hospital, the patient had a temperature of 38.3°C; oxygen saturation of 94%; a confluent, macular, blanching, non-pruritic rash on his trunk (Figure); and a fine, petechial rash on his ankles. He had bibasal inspiratory crackles but no peripheral oedema. A chest x-ray showed small bilateral…