Febrile rash and convalescent rash of dengue fever

Abstract

A 1-year-old boy infant presented with fever for 3 days. On examination he was febrile and his face, trunk and extremities were erythematous which blanched upon pressure (Fig. 1). His platelet count dropped to 83,000 per μL on day 5 of illness. His dengue serology IgM was positive suggestive of primary dengue infection.A 9-year-old girl presented with fever for 4 days. On day 8 of illness, when her fever subsided, she developed hypotension. Her platelet count dropped to 15000/ml and hematocrit increased to 42.8%. She was resuscitated with fluid boluses. She developed typical dengue rash of convalescence 3 days after defervescence (Fig. 2). Her dengue serology IgM and IgG were positive, suggestive of secondary dengue infection.During the first 24-48 hours of fever, children with dengue fever may develop a transient generalized macular erythematous rash which blanches upon pressure. The convalescent rash of dengue fever appears about 2-3 days after defervescence. It is characterized by generalized confluent petechial rash which does not blanch upon pressure, with multiple small round islets of normal skin. It is otherwise called "white islands in a sea of red". Some children with this rash may experience generalized pruritus. This rash gradually fades over one week. FIG. 2 Convalescent rash of dengue -"White isles in the sea of red". Darier-White DiseaseA 6-years-old boy presented with multiple dark, raised lesions all over the body since 1 year (Fig. 1a). The disease began with discrete hyperpigmented hyperkeratotic papules over the knee and elbows which later progressed to involve the preauricular region, ear lobe, neck, both flexor and extensor aspect of upper limbs and lower limbs and buttocks (Fig. 1b). There was history of photoexacerbation of the lesions. The child complained of pruritus and difficulty in sitting due to pain because of multiple hyperkeratotic lesions over the buttocks. There was presence of palmar pits. Oral mucosa and nails were normal. His 4-year-old sibling also presented with similar lesions over the knees and elbows. A clinical diagnosis of Darier-White disease was made. Histopathological examination from punch biopsy of a lesion showed acantholysis along with classical dyskeratosis and hyperkeratosis in the epidermis.

A study of clinical and laboratory profiles of dengue fever in children

“…Some of them also had an erythematous rash which was different from the rashes noticed during the initial part of the illness. This rash was not blanchable, more confluent with islets of healthy skin which has been describedas "white islands in a sea of red" [21,22].…”

Dengue convalescent rash

“…Dengue virus replicates in vascular endothelial cells leading to endothelial swelling, perivascular oedema, and mononuclear cell infiltration which results in release of various proinflammatory cytokines and thus precipitating the injury. 7 Despite high incidence of dengue in India, Dengue rash is an uncommon clinical finding in countries like India due to darker skin shades. Though any co-relation between cutaneous manifestations and severity of illness have yet not been established, further research might help in establishing association between extent of skin involvement and organ involvement.…”

Isles of white in a sea of red: an underdiagnosed entity?

“…Dengue infection can sometimes lead to a peculiar type of confluent erythematous or petechial rash, which does not blanch on pressure, with small areas of normal skin termed as ‘isles of white in a sea of red’ 2. These types of rashes appear during periods of defervescence and gradually fade over 1 week.…”