Oregon Trail

A traveler to south-central Asia, southeast Asia, and southern Africa comes to your clinic two weeks after returning to the U.S. He has fevers and chills without rigors. On exam, you note bradycardia despite a temperature of 39. You're not sure what is going on so you send him home. He returns a week later with abdominal pain and a rash shown below.

You still don't know what's going on so you make a referral to some subspecialists. Unfortunately, a week later, he presents acutely to the emergency department with hepatosplenomegaly, intestinal bleeding, and peritonitis. He undergoes exploratory laparotomy and is found to have ileocecal perforation. Pathology shows lymphatic hyperplasia of the Peyer's patches.

Challenge: What happened here?

Image is in the public domain.