==== Front IDCasesIDCasesIDCases2214-2509Elsevier S2214-2509(18)30107-010.1016/j.idcr.2018.e00421e00421ArticleMorbilliform skin rash with prominent involvement of the palms in Chikungunya fever Tini Maria Laura aRezza Giovanni giovanni.rezza@iss.itb⁎a ASL-RM2, Roma, Italyb Department of Infectious Diseases, Istituto Superiore di Sanità, Roma, Italy⁎ Corresponding author at: Department of Infectious Diseases, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161, Roma, Italy. giovanni.rezza@iss.it04 7 2018 2018 04 7 2018 13 4 4 24 5 2018 2 7 2018 2 7 2018 © 2018 The Authors. Published by Elsevier Ltd.2018This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).An outbreak of chikungunya occurred in Central Italy in the summer of 2017. During the outbreak, two siblings with fever and joint pain developed a morbilliform skin rash with prominent involvement of the palms. Knowledge of the characteristics of chikungunya exanthem is important to adddress clinical diagnosis. Keywords ChikungunyaSkin rash ==== Body A 21 year old man living in Rome presented, on August 26, 2017, with a two-day history of high fever (39.6 °C), malaise, joint pain, and a morbilliform skin rash. The skin rash affected the face, trunk, upper limbs, and lower limbs (Fig. 1). Weakness and joint pain (ankles and wrists were slightly swollen) lasted for over two months after recovery from the acute disease. His sister, a 15 year old girl, developed the same symptoms with fever onset (38 °C) on August 25. The rash developed on the 2nd day. Joint pain affected the wrists, which appeared swollen, lasting for two months after acute disease onset. The exanthema involved the palm of the hands, particularly the fingertips, which were intensively flushed in both patients (Fig. 2, Fig. 3).Fig. 1 Manifestations of chikungunya skin rash. Skin rash on patient’s leg. Fig. 1Fig. 2 Manifestations of chikungunya skin rash. Palm involvement on the hand of the 21-year-old man. Fig. 2Fig. 3 Manifestations of chikungunya skin rash. Palm involvement of the 15 year-old girl. Fig. 3 Since an outbreak of chikungunya had been identified near the city of Roma, this diagnosis was hypothesized. On mid-September, blood samples sent to the Spallanzani hospital laboratory in Roma were positive for anti-chikungunya virus antibodies (IgM titer was 1:320 and IgG 1:640 in both patients). Blood counts and liver enzymes were within the limits. Chikungunya is a vector-borne disease, caused by an Alphavirus transmitted by Aedes spp. mosquitoes. In Italy, two chikungunya fever outbreaks occurred in 2007 and in 2017 [1,2]. During the last outbreak, sporadic cases and small clusters were reported also in the city of Rome [2]. Chikungunya fever is characterized by fever, prominent and sometimes long-lasting joint pain, and a generalized maculo-papular skin rash. Differently from measles, after an initial facial flushing, the face is often spared by the exanthema. Palm involvement is not pathognomonic of chikungunya fever, and has been described also in other alphavirus fevers, such as Mayaro and Ross River disease [3,4]. In conclusion, a diagnosis of chikungunya fever should be considered when cases of fever with joint pain, accompanied by a skin rash, which may involve the palm of the hands, occur during the hot season in areas with presence of Aedes spp. mosquitoes. Declaration of interests No competing interests. Authors’ statement The authors declare they do not have any conflict of interest, they received written informed consent from the patients, and all the work has been done in complete transparency. Contributors MLT cared for the patients, and GR supervised and wrote the report. Acknowledgements We thank the lab of the INMI Spallanzani in Roma for CHIKV serology. We also thank the two patients and their mother for the collaboration and for having authorized the publication. ==== Refs References 1 Rezza G. Nicoletti L. Angelini R. Infections with chikungunya virus in Italy: an outbreak in a temperate region Lancet 370 2007 1840 1846 18061059 2 Venturi G. Di Luca M. Fortuna C. Detection of a chikungunya outbreak in Central Italy, August to September 2017 Euro Surveill 22 September (39) 2017 3 Pincus L.B. Grossman M.E. Fox L.P. The exanthema of dengue fever: clinical features of two tourists traveling abroad J Am Acad Dermatol 58 2008 308 316 17959270 4 Keighley C.T. Saunderson R.B. Kok J. Dwyer D.E. Viral exanthems Curr Opin Infect Dis 28 2015 139 150 25706914