a 45-year - old man presented with a symmetric rash over his lower legs associated with recurrent fever following a hiking trip in southern europe . he traveled to rome , florence , and athens and hiked in the calabria region of south italy for 10  days . on his return flight he developed swelling and erythema of his ankles spreading proximally . the patient did not recall any tick bites or being in the vicinity of sick contacts . he denied ever having any dental procedures but was noted to have poor dental hygiene on examination of the oral cavity . upon arrival home he experienced recurrent fevers up to 38.9  c on a daily basis . he was evaluated by his primary care physician who prescribed 7  days of clindamycin for presumed cellulitis with no clinical improvement . the patient was febrile ( 39.1  c ) , tachycardic ( 116 beats per minute ) with signs of mild dehydration . cardiovascular examination was pertinent for significant bilateral pitting edema of both legs from the dorsa of the feet to the knees . admission labs showed a leukocytosis 11.4    10/l ( 3.510.5    10l ) , lactate 2.7  mmol / l ( 0.91.7  mmol / l ) and a normocytic anemia ( hemoglobin 9.5  g / dl [ 13.517.5  g / dl ] , mean corpuscular volume 92.5  fl [ 81.295.1fl ] ) with 2.7% reticulocytes ( 0.52.5% ) . he had an erythrocyte sedimentation rate ( esr ) of 71  mm/1  h ( 022  mm/1  h ) and quantitative serum c - reactive protein level of 98.9  mg / l ( < 8.0 he was treated for sepsis likely secondary to lower limb cellulitis with intravenous vancomycin , cefepime and doxycycline . however he had persistent recurrent fever with progressive worsening of the rash 24  h into his admission . human immunodeficiency virus , hepatitis b and c serologies were negative as were assays for rickettsiae , brucella , lyme disease , leishmaniasis and q fever . a transthoracic echocardiogram ( tte ) showed a mobile echo density ( measuring 8  mm    1.2  mm ) arising from the ventricular surface of the aortic valve . this was confirmed on transesophageal echocardiogram ( tee ) , and the patient was switched to iv ceftriaxone for treatment of native - valve endocarditis . the rash was deemed to be an infectious vasculitis as a skin manifestation of infective endocarditis . the patient did not have any prior cardiac history , rheumatic fever or recent dental work . blood cultures were positive for an organism within the streptococcus gallolyticus group ( time to detection of 32  h ) . he subsequently underwent a screening colonoscopy to rule out colorectal pathology given the association with s. gallolyticus subsp . the patient completed 6 weeks of intravenous ceftriaxone with complete symptomatic resolution repeat esr and crp were back to baseline levels . the patient s rash manifesting as an infectious vasculitis was the only sign of infective endocarditis . this case highlights the need to refine a differential diagnosis for infectious etiologies based upon their geographic distribution . however , when a standard workup for fever and a rash in a returning traveler is negative , a broader differential diagnosis must be entertained .
a 45-year - old man was admitted for investigation of a symmetric lower limb rash associated with recurrent fever for two weeks following a hiking trip in italy and greece . 
 he was treated for sepsis secondary to lower limb cellulitis with no clinical improvement and subsequently diagnosed with streptococcus gallolyticus endocarditis mediating an infectious vasculitis .