By Ted Rosen, MD, FAAD, Editor-in-Chief
A souvenir from an exotic trip
A previously healthy 70-year-old white woman, a retired insurance agent, presented with influenza-like symptoms and an eschar on her nose shortly after completing a 2-week-long tour of South Africa. During her trip, she denied visiting any other African country, and said she had visited urban, rather than rural, destinations. She did go on a full-day photographic safari, but never walked in the high grasses surrounding the safari vehicle. One interesting stop was a visit to a kennel that bred and exported dogs native to the region (Boerboels and Rhodesian Ridgebacks).
Six days after the patient returned to the United States, she developed fever (documented to 102.40F), chills, headache, and diffuse myalgia. Shortly thereafter, she noticed a faint rash on her palms and soles and a large, tender pustule on her nose. She presented to her dermatologist 9 days after her return from Africa because the nasal pustule had evolved into an unsightly eschar (Figure 1).
She did not recall an overt insect bite or anyone else from the group with similar symptoms while still in, or on the way back from, South Africa. She had no other notable medical problems and did not take any medications. She was a non-smoker, non-drinker and did not use illicit drugs. She denied any sexual activity for at least 6 months before the trip and during the excursion. Past medical history was significant only for many actinic keratoses and several basal cell carcinomas.
Laboratory studies disclosed an increased white blood cell count of 12,800 cells/mm3, but all other routine labs were within normal limits. RPR was non-reactive. She refused a skin biopsy.
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