CASE REPORT

A 52 year old woman was admitted with fever and acute polyarthritis. She had visited a game reserve in Northern Province, South Africa 5 weeks before admission. Two weeks before admission she developed fever and flu-like symptoms, then mouth ulcers, and a non-itchy, maculopapular rash that covered her whole body and her scalp. Three days after the start of the rash she developed painful and swollen joints—notably, the hands, elbows, wrists, knees, and feet.

On examination at admission she was apyrexial with no visible rash and no lymphadenopathy. She had florid synovitis at elbows, wrists, knees, and dactylitis affecting the right index finger (fig 1A), left thumb, and left 4th toe. Spinal movement was normal. Examination was otherwise unremarkable.