White islands in the sea of red

A 9-year-old boy was brought by the parents with complaints of fever and rash for 5 days duration. It was accompanied by generalized malaise and arthralgia. The rash started around the face and then spread to involve the trunk and extremities. There was no bleeding history, headache, or abdominal pain alongside the rash. Examination revealed that the presence of diffuse erythematous maculopapular rash over the trunk, and extremities with few islands of sparing noted between [Figure 1a]. There were petechiae which were noted in the oral cavity, conjunctiva, flexures, and pressure areas. The Rumpel-Leede test was positive suggested by the presence of ecchymosis along the Sphygmomanometer cuff sites and cubital fossa [Figure 1b]. Hence, a diagnosis of dengue hemorrhagic fever (DHF) was made and was serologically confirmed. Dengue fever is a mosquito-borne arboviral infection that can have an incubation period of 5–8 days. The cutaneous manifestation can vary based on the age group and severity usually starting with facial flushing progressing to diffuse maculopapular rash. Some individuals might show areas of sparing alongside the maculopapular rash which is referred to as “white islands in a sea of red.” This clinical clue can be very helpful in the diagnosis of DHF in the absence of seropositivity in the early stages.^[1]

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Figure 1:

(a) Diffuse erythematous maculopapular rash with areas of sparing appearing as “white islands in the sea of red.” (b) Positive Capillary fragility test or Rumpel-Leede phenomenon.

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