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A 20-year-old woman presents to the emergency department with complaints of 1 day of headache and fever with associated nausea, vomiting, and a diffuse red rash. She reports she has been on spring break for the past week, during which time she has been drinking heavily and spending most of each day in the sun, either hiking or on the beach. However, she has used SPF 30 sunblock and does not remember getting a sunburn. Her last menstrual period began 3 days ago. She denies any recent sexual activity. Examination is notable for a diffuse rash (pictured) that includes her palms and soles. Her neck is supple and she does not exhibit any photophobia or signs of intoxication. Twenty minutes after presentation she becomes lethargic, and her temperature is 39.6°C (103.3°F), heart rate is 115/min, blood pressure is 84/48 mm Hg, and respiratory rate is 18/min.
Which of the following is the most likely diagnosis?
A. Alcohol poisoning
C. Neisseria meningococcemia
D. Rocky Mountain spotted fever
E. Toxic shock syndrome
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