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The patient is a 10-year-old girl who presents to urgent care with 3 days of fever, headache, muscle aches, nausea, and a skin rash. She has a temperature of 102°F. On examination you find numerous erythematous macules and purpura on her palms and the soles of her feet.

The patient is immunocompetent with an unremarkable medical history. Her mother recounts no recent travel from their home in North Carolina, but notes that the patient spent a day gardening with her grandmother approximately 1 week prior to the appearance of the rash and other symptoms. The mother is concerned this could be an allergic response to contact with a toxic plant or a response to a bug bite.

View the photo and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page.

Suspicious Rash, Rocky Mountain spotted fever Image
Figure 1.
A 10-Year-Old with Fever, Headache, Muscle Aches, Nausea—and a Suspicious Rash