Author: Harry Melville, Etienne Chew / Editor: Nick Tilbury / Codes: DP1, IC5, IP2, SLO1 / Published: 12/04/2023

A 28-year-old man who was previously fit and well presents to the emergency department (ED) overnight. Two-weeks ago he returned from a holiday on the Arabian Peninsula where he attended a religious festival. He has had 5 days of fever, sore throat, coryza and sore, red eyes. Today he became concerned that his fever was not resolving and that his facial acne was “coming back”. He denies other symptoms.

Aside from acne, his past medical history is unremarkable and he takes no regular medications. He denies any history of unprotected sex, swimming in open waters, animal contact, or ingestion of any high-risk foods or unsanitary water during his holiday. He also did not feel unwell while abroad and denies any contact with anyone who was ill.

He did not take any malarial prophylaxis, and is unaware whether his vaccinations are up to date.

On examination he has the beginnings of an erythematous maculopapular rash on his face. He is feverish at 38.9 degrees (C) and on closer inspection, you notice that he has multiple white spots on his oral mucosa. His examination is otherwise normal.

Bloods show a lymphopaenia, elevated CRP and deranged transaminases. ECG reveals a sinus tachycardia of 115bpm.

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