40 yo M with fevers, sore throat, and a rash


Click here for a interactive 5 min version of this case on the Human Diagnosis Project.


40 yo M who presents with a fever, sore throat, and rash. He first developed fevers, chills, sore throat, and a productive cough 2 weeks ago while traveling in Europe. He notes multiple sick contacts at that time. He has had a cough productive of green/yellow sputum and severe throat pain limiting his ability to swallow but denies any chest pain or shortness of breath. Over the past 12 hours, he developed a nontender, nonpruritic red rash that started concurrently on his chest, back, and upper thighs. He reports myalgias and arthralgias without any noted joint swelling or redness.

He has a history of bipolar disorder and takes lamotrigine. He has taken ibuprofen and APAP sparingly over the past week without relief of his symptoms. He uses ETOH and THC socially.

His physical exam is notable for T of 39.2C, HR 96, RR 20, BP 100-110s/40-60s, SaO2 95% on RA. He appears well and in no distress. His posterior oropharynx showed erythematous 2+ tonsils with tonsillar exudates. He has crackles and tubular breath sounds in the R upper lung fields. His skin is notable for a flat, erythematous, blanching patch over his chest, neck and abdomen without a papular component and spares the palms and soles.

His initial labs are notable for Na of 133, WBC of 16 with left shift, normal lactate (full labs). A flu swab was negative and rapid strep test was positive.

His CXR shows:

Click to enlarge. 

He had a CT neck which did not show any peri-tonsillar or retropharyngeal abscess.

What is your differential for his rash?


How would you manage this patient? What are you concerned about? 



How do you treat it?  




  1. Bisno, AL & Stevens, DL. 1996. Streptococcal Infections of Skin and Soft Tissues. NEJM. 334(4): 240-245.
  2. Wilkins, AL, et al. 2017. Toxic shock syndrome – the seven Rs of management and treatment. Journal of Infection. 74(1): S147–S152.
  3. Stevens, DL. Epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock syndrome. In: UpToDate, Sexton, DJ (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017)
  4. Stevens, DL. Treatment of streptococcal toxic shock syndrome. In: UpToDate, Sexton, DJ (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017)
  5. Chu, VH. Staphylococcal toxic shock syndrome. In: UpToDate, Baron, EL (Ed), UpToDate, Waltham, MA. (Accessed on February 23, 2017)