A 62-year-old Mediterranean man presented with a 4-day history of chills, shivering, fever (40°C), general fatigue, nonpruritic maculopapular rash, and muscle weakness. He developed the chills 6 days after working on a farm near the mountains surrounding Madrid, Spain, then noticed an insect bite on his left elbow.
The maculopapular rash first appeared on his forearms and extended to his trunk; it spared his palms and soles. Examination also revealed a single ulcerative lesion on his left elbow, approximately 15 mm in diameter, covered by a dry, black eschar. He had lymph node enlargement in his left axilla. The rest of the physical examination did not reveal hepatosplenomegaly or other abnormalities.
Laboratory analyses showed the following values: hemoglobin, 14.9 g/dL; leukocyte count, 4300/L with predominant neutrophils; mild thrombocytopenia (platelet count, 132 × 103/L); aspartate aminotransferase, 73 IU/L; alanine aminotransferase, 47 IU/L; mild hyponatremia (sodium, 131 mg/dL), C-reactive protein, 60 mg/dL. Chest radiographs were unremarkable.
The most likely diagnosis is
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Trypanosomiasis
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Mediterranean spotted fever
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Lyme disease
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Q fever
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Dengue
Answer on page 807
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