Case Presentation: A 36-year-old Dominican female, G3P2002, at six weeks gestation and no significant medical history presented with complaints of fever, headache, myalgias, nausea, vomiting, diarrhea, and diffuse abdominal pain for two days. She denied any recent travels, sick contacts, or any bug bites or ticks on her body. Patient is only allergic to penicillin (develops a rash). She denied taking any medications prior to her presentation. Upon initial exam, she was febrile to 100.8F, tachycardic, normotensive, and without tachypnea. She had left periorbital and bilateral parotid swelling and tenderness, diffuse abdominal tenderness, hepatosplenomegaly, and lower and upper extremity tender, pruritic and erythematous maculopapular rash, which erupted on that day. Initial labs showed anemia, leukopenia, and transaminitis, while a cerebrospinal fluid analysis resulted negative.
Given high suspicion for a Rickettsial infection and increased incidence of Zika, West Nile Virus, Chikungunya, and other infectious diseases in New York City, the patient was empirically treated with chloramphenicol, azithromycin, and acyclovir, and was placed in isolation until results of the extensive serologic analysis (which included many viral, bacterial, fungal, and parasitic agents) revealed a potential source. During her stay, the rash ascended towards the patient’s groin and neck, while remaining pruritic and painful as diphenhydramine failed to provide relief. At this point, she also began to complain of bilateral facial tingling and photophobia. After extensive investigations and collaboration with the infectious disease, hematology, and dermatology teams, it was determined the patient had a primary Epstein-Barr Virus (EBV) infection, which led to the development of urticarial vasculitis (UV). Therefore, the treatment was modified to provide symptom relief, add corticosteroids, and discontinue the antibiotics.

Discussion: UV is an uncommon subtype of cutaneous vasculitis characterized by the presence of painful, pruritic, and erythematous wheals that persist for more than 24 hours. These can be found anywhere on the body, are resistant to antihistamines, and can be caused by connective tissue diseases, drugs, or infections from sources such as EBV, Borrelia burgdorferi, and hepatitis A, B or C virus. Primary EBV infection is considered a self-limited illness, and treatment includes rest, hydration, analgesics, and antipyretics. However, using corticosteroids in the setting of EBV and UV provided adequate symptomatic relief, and prevented UV’s progression to the rest of the patient’s body. Currently, even though the EBV vertical transmission rates are low, and evidence from case reports and other epidemiologic studies have argued against EBV as a cause of congenital infection, there are no cohesive evidence-based guidelines for its management during the prenatal and postpartum periods.

Conclusions: A painful and pruritic ascending rash, when initially found along fever, headache, myalgias, and diarrhea in a pregnant patient, compels the hospitalist to deliver a prompt diagnosis and empiric treatment due to the detrimental associations of many intrauterine infections with fetal and/or neonatal disease. Because susceptibility to primary EBV infection has only been reported in 3.0-3.4% of pregnant women, primary infection during pregnancy has been deemed rare, and proven to be a diagnostic challenge in a geographic setting with a diverse patient population and multiple endemic infectious diseases.