A man in his fifties presented to the emergency department with four days of fever and a diffuse rash. The rash had begun as circular, red, flat lesions on his arms and torso (Fig. 1) that evolved into serpiginous rings over his entire body except for head, neck, palms, and soles. The skin lesions were not painful or pruritic. During this same period, he experienced myalgias and arthralgias worst in his gluteal area, and chills. He took anti-inflammatories at home with temporary partial relief of fevers, arthralgias, and myalgias. He denied headache, sore throat, and chest pain.

Six days prior to presentation he sustained a splinter to the tip of the left middle finger from a citrus tree. Localized swelling and erythema without purulence developed where the splinter had penetrated the skin. Five days prior to presentation, while in the woods, he fell and sustained bruises and lacerations to his face, scalp, and thigh.