Author: Nithin Natwa, MD
Co Author #1: Zachary Goldstein
Co Author #2: Jeffrey Kovan

Patient Presentation:
Initial patient presents with fever refractory to non steroidal anti-inflammatory drugs, sore throat and fatigue with later onset of rash involving the extremities. Following the initial patient, 3 other patients on the same football team presented with similar symptoms (1 did not have a rash).

History:
On a high school varsity football team one player initially presented with a fever of 102F with progression to a sore throat. Viral pharyngitis was diagnosed by primary care physician. Athlete was held from football.
The rash on the extremities appeared one day later along with increased fever(104F).
While this athlete was held from sport, three other players presented with similar symptoms over the next two weeks. One did not have a rash, all had fevers greater than 101F, sore throat and fatigue. All athletes missed 3-5 practices and only one missed school due to the football season starting before school was in session.
All patients denied night sweats, nausea, vomiting, neck stiffness, vision changes, syncope, bowel/urinary changes, weakness, chest pain, abdominal pain and shortness of breath. Athletes denied any recent diet changes, unintentional weight loss or travel history. All athletes reported being up to date with vaccines. There were no oral or genital ulcers/rash reported at any period by any of the athletes.

Physical Exam:
Initial Patient Physical Exam:
Vital Signs: 102F fever measured by oral thermometer
Head Eyes Ears Nose Throat: no oral mucosal lesions or exudates noted, erythematous pharynx. No swollen/tender lymph nodes, clear sclera, pupils equally reactive to light, extra-ocular motion intact. Normal neck range of motion, no sinus tenderness, tympanic membranes normal bilaterally
Cardiac: Regular rate and rhythm
Respiratory: clear to auscultation bilaterally
Abdomen: normal bowel sounds, nontender to palpation
Neurologic: sensation intact, no cranial nerve abnormality. Negative kernig's/brudzinski test. Deep tendon reflexes intact bilaterally
Skin: Small blisters on the palms of the hands, soles of the feet, erythematous flat rash on the arms and legs.
Genitourinary: No rash noted

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