![]() ![]() Native computed tomography (CT) of the chest revealed an enlarged lymph node (3.0 × 3.6 cm) in the right axilla. The rest of the physical examination was unremarkable, as were the electrocardiogram and chest radiograph. Except for the two palpable, axillary lymph nodes and the follicular skin rash, the patient complained of pain on firm palpation in both lower legs both ankles and feet were slightly swollen. The patient weighed 68 kg and her height was 170 cm with a body mass index (BMI) ofĢ3.5 kg/m 2, her neck was supple, her blood pressure was 112/73 mm Hg, and the heart rate was 65 per minute and regular. After one of the skin lesions on the thighs was biopsied, the patient and her 4‑month-old daughter were admitted to the department of internal medicine for further work-up. She still had nocturnal fever with temperatures up to 39.0 ☌ and there was now a second palpable, indolent lymph node in the right axilla. The skin rash was unchanged, but she additionally complained of pain in both lower legs, the ankles and her left foot were swollen. At the follow-up visit 2 weeks later the patient reported worsening of her condition. The patient’s laboratory tests were notable for hemoglobin 11.7 g/dl (normal: 12.0–15.3 g/dl), hematocrit 34.8% (normal: 35.0–45.0%), alkaline phosphatase 153 U/l (normal: 35–105 U/l), gamma-glutamyl transferase (GGT) 42 U/l (normal: <38 U/l), aspartate-amino transferase (AST) 37 U/l (normal: <30 U/l), alanine aminotransferase (ALT) 49 U/l (normal: <35 U/l) and C‑reactive protein (CRP) 37.3 mg/l (normal: <5.0 mg/l). ![]() Serology for syphilis and human immunodeficiency virus (HIV) was negative, as was direct examination for scabies. An enlarged firm lymph node was palpable in the left axilla. The patient reported fever, mainly during the night and some improvement with paracetamol. The rash appeared on the hands and feet of the breast feeding woman 2 weeks later with small skin lesions that exsiccated after secretion of a milky exudate. She was diagnosed with folliculitis and an ointment with a combination of betamethasone and gentamicin was prescribed for topical treatment. The patient attended the dermatology outpatient clinic 3 weeks before admission because of a skin rash on her back and fever. After an unremarkable pregnancy and 4 months before the current admission she gave birth to a second healthy child. The symptoms subsided when she became pregnant with her first child. These symptoms were treated with unspecified injections and oral medication for 5 days. Her travel history was negative since arrival in Austria her medical history was positive for arthralgia and a skin rash 2 years earlier, when she was still living in Nigeria. The black African patient had immigrated from Lagos, Nigeria 18 months before admission to Austria to join her husband, who had immigrated to Austria 13 years earlier. ![]()
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