A previously healthy 17-year-old boy presents with a 3-day history of a pruritic maculopapular rash, fever (to 104℉ 40℃), vomiting, and diarrhea to a children's hospital in the south-central United States during the winter of 2018. These symptoms were preceded by 2 days of nausea, myalgia, and associated dizziness. His rash initially began on the upper chest and neck before progressing to his trunk and extremities. The patient has a family history of systemic lupus erythematosus (SLE) and was exposed to family members diagnosed as having influenza confirmed by rapid testing. Three days before admission, he was prescribed oseltamivir for presumed influenza, which was discontinued after 2 doses due to concern for drug reaction with the emergence of his rash. The patient and his immediate family deny any recent travel, and he is fully vaccinated. A sexual history was not obtained on admission. At presentation, he has an 8-lb weight loss during his acute illness and appears ill, with a temperature of ioi.6℉ (38.6℃), heart rate of no beats/min, respiratory rate of 20 breaths/min, and blood pressure of 111/52 mm Hg. On examination he is alert and answering questions appropriately. Cardiac examination reveals tachycardia with regular rhythm but without murmurs, rubs, or gallops. Capillary refill is delayed to 4 seconds, and pulses are 21 peripherally. Pulmonary and abdominal examination findings are normal, without organome-galy. His rash is deeply erythematous, blanching, and pruritic. Many macules coalesce into a morbilliform eruption that involves his chest and abdomen, with isolated macules along the extremities and left palm (Fig). There is no mucosal involvement or lymphadenopathy.
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