Exanthema associated with Zika virus infection

A 39-year-old man presented to the Acute Febrile Illness walk-in clinic with acute onset of rash and conjunctival swelling after 2 days of frontal headache, sore throat, and diff use myalgia. He did not have fever, diaphoresis, photophobia, or bleeding symptoms and reported no comorbidities. At physical examination, he had oedema and erythema of the malar region of the face and conjunctival injection (fi gure A) and a macular rash on the trunk and abdomen (fi gure B). Hyperaemia and petechiae were seen in the hard palate (fi gure C). There was a tender, mobile, soft lymph node, approximately 15 mm in diameter, behind the left ear (fi gure D), and multiple smaller palpable submandibular and cervical nodes bilaterally. Results of blood tests were within normal limits and urinalysis revealed haematuria. The patient lived in an impoverished area of Rio de Janeiro that is endemic for dengue, had not travelled recently to other areas of the country, and was not aware of any contact with other ill people. As part of the syndromic diagnosis, serology tests were performed for dengue, cytomegalovirus, toxoplasmosis, Epstein–Barr virus, syphilis, and HIV, the results of which were all negative. RT-PCR for dengue and chikungunya were also negative. Because of the recent introduction of Zika virus in the country, we did specifi c RT-PCR for Zika virus RNA, with a positive result. The patient had no alarm signs for severe dengue fever and was instructed to return the following day for re-evaluation. He returned 14 days after the onset of symptoms for reassessment, and had completely recovered. At the time of writing, the patient was healthy. Zika virus is transmitted by mosquitoes of the genus Aedes, which are widespread in Brazil and contribute to dengue transmission. The emergence of Zika in a naive population with high susceptibility to transmission requires physicians to be alert to its occurrence in order to characterise its manifestations and establish robust and reliable clinical surveillance.