Spared Island of Normal-Looking Skin is Not a Monopoly of Dengue Rash : Indian Journal of Paediatric Dermatology

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Spared Island of Normal-Looking Skin is Not a Monopoly of Dengue Rash

Dhar, Sandipan; Ganjoo, Shikhar1,; Choudhury, Jaydeep2

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Indian Journal of Paediatric Dermatology 23(3):p 254-255, Jul–Sep 2022. | DOI: 10.4103/ijpd.ijpd_87_21
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A 3-year-old girl presented with clinical features suggestive of toxemia and diffuse widespread rash with areas of normal looking skin. On investigation, she was found to be negative for dengue nonstructural protein (NS1) antigen and immunoglobulin M (IgM) serology and had a positive blood culture for Streptococcus pneumoniae.

Streptococcus is well known to cause exanthems in children. Maculopapular rash is the most common exanthem and these are mostly exotoxin mediated. Group A beta hemolytic streptococcus (GABHS) and Streptococcus pyogenes are the most common organisms involved. Diffuse widespread rash with islands of sparing is considered to be characteristic of dengue fever. We report a child with streptococcal toxemia and diffuse rash with islands of normal looking skin.

A 3-year-old girl born to nonconsanguineous parents presented with a 10-day history of high-grade fever associated with rigors, chills, vomiting, and myalgias. The child had an incomplete vaccination history. There was no history of drug intake before presentation. On examination, diffuse widespread maculopapular rash was present for the past 5 days which rapidly spread to involve both the upper, lower extremity and trunk with particularly conspicuous islands of sparing of normal looking skin [Figure 1a and b]. The rash was bilaterally symmetrical and nonblanchable. There was glazed erythema over both palms and soles and a relative sparing of face and mucosa [Figure 2]. Other systemic examination was normal. Investigations revealed an elevated white blood cell count (16,430/mm3) with absolute neutrophil count (10,620/mm3), elevated C-reactive protein, and moderate elevation of hepatic transaminases. Other laboratory tests and radiological examination including urea, creatinine, creatine kinase, and chest X ray were found to be normal. The child tested negative for IgM antibodies and NS1 to dengue virus. Blood culture revealed S. pneumoniae which confirmed the diagnosis of streptococcal pneumonia septicemia. The child received intravenous ceftriaxone for 10 days. Upon treatment, fever resolved by the 7th day while skin rash subsided by the 10th day.

Figure 2:
Rash present over the lower extremities with glazed erythema of the soles

Exanthems due to streptococcus are a well-known entity. Fine, erythematous maculopapular eruption involving the trunk and extremities is caused by streptococcal exogenic pyrotoxin which is produced by GABHS. It is classically considered to have a sandpaper appearance and resolves with thick sheets of desquamation, especially prominent over the palms and soles. Oral mucosa can be involved presenting as white strawberry tongue.[1] Streptococcal toxic shock syndrome caused by S. pyogenes is mediated by scarlet fever toxin A. It presents as widespread macular erythema and scarlatiniform rash along with multisystem organ failure.[2] The association of streptococcal pharyngitis with guttate psoriasis is also well known which can be triggered by perianal streptococcal infection.[34]

Island of normal looking skin classically known as white islands in a sea of red is typically seen in recovery stage of dengue and one can successfully predict the platelet recovery looking at this type of rash.[5] To the best of our knowledge, there is no report of a rash with island of sparing caused by streptococcal septicemia as such a presentation was considered to be a unique feature of dengue fever. In our case, the patient presented with multiple areas of normal looking skin in between the streptococcal toxemic maculopapular rash which is a rare phenomenon.

Declaration of consent

The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1. Brinker A. Scarlet fever N Engl J Med. 2017;376:1972
2. Lewis DJ, Chan WH, Hinojosa T, Hsu S, Feldman SR. Mechanisms of microbial pathogenesis and the role of the skin microbiome in psoriasis: A review Clin Dermatol. 2019;37:160–6
3. Dupire G, Droitcourt C, Hughes C, Le Cleach L. Antistreptococcal interventions for guttate and chronic plaque psoriasis Cochrane Database Syst Rev. 2019;3:CD011571
4. Garritsen FM, Kraag DE, de Graaf M. Guttate psoriasis triggered by perianal streptococcal infection Clin Exp Dermatol. 2017;42:536–8
5. Srivastava A. Dengue fever rash: White islands in a sea of red Int J Dermatol. 2017;56:873–4
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