Diagnosing a Rash

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    Morning ReportSeptember 21, 2011

    Annie Powers

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    Case PresentationChief Complaint: Rash and fever

    HPI:

    Previously healthy 6 year old female presents with a 6-7 day history of URI symptoms and fever

    A four day history of rash, which began on her trunkand spread to her extremities

    A two day history of red eyes Seen at an Urgent Care and started on Omnicef for

    presumed GAS and tobramycin eye drops

    Lip and tongue swelling began the day of admission

    Presented to JVH for worsening mouth and lip swelling

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    Case Presentation ROS: Positive for rash, lip swelling, fever, conjunctivitis,

    cough, decreased PO intake, pain with urination

    PMHx: History of two UTIs, sickle cell trait, nohospitalizations or surgeries

    Meds: Omnicef, tobramycin eye drops, Tylenol

    Allergies: NKDA

    Immunizations: Up to date FamHx: Diabetes and asthma

    SocHx: Lives with mother, grandmother, 2 aunts and 2siblings. No sick contacts. No recent travel.

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    Case PresentationPhysical Examination:

    Vital Signs: T 38.6, HR 134, RR 21, BP 94/54, O2 93% on RA

    General: Alert and cooperative, but appearsuncomfortable.

    HEENT: Bilateral scleral and conjunctival injection withoutany mucopurulent discharge. Lips are very dry, swollenand cracked with yellow healing eschars. Posteriorpharynx with tonsillar hypertrophy and erythema overgingiva. Shotty anterior cervical LAD.

    CV: Tachycardic, no murmur.

    Lungs: CTAB, no wheezing, crackles or retractions.

    Abd: Soft, non-tender, non-distended.

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    Case Presentation:Physical Examination:

    Skin: Pink to red targetoid papules with central

    hemorrhagic crusting. Scattered macules on thebilateral palms and soles. No vesicles or bullae wereseen on exam. Areas of excoriations.

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    Case Presentation Laboratory:

    CMP: Na 137, K 4.5, Cl 100, CO2 27, BUN 10, Cr 0.8,Glucose 108, Ca 9.9, Protein 7.5, ALT 26, AST 28

    CBC: WBC 14.2; (N76, L11) Hgb13.1, Platelet 397

    ESR: 57

    CRP: 1.8

    UA: 3+ ketones with spec gravity of 1.02 otherwise negative

    Blood and urine cultures: pending

    VPR: pending

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    Differential Diagnosis

    6 year old female with fever, rash,conjunctivitis and mucosal ulcerations

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    Differential Diagnosis Erythema multiforme

    Photoxic eruptions

    Toxic shock syndrome Staphylococcal scalded skin syndrome

    Paraneoplastic pemphigus

    Erythroderma

    Pustular drug eruptionsma and erythematous drugeruptions

    Viral infections: Adenovirus, enterovirus, varicella, HSV

    Kawasaki Disease

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    Differential DiagnosisErythema multiforme Drug eruption

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    Differential DiagnosisToxic Shock Syndrome Staphylococcal Scalded Skin Syndrome

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    Differential DiagnosisKawasaki Disease

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    Differential DiagnosisVaricella zoster virus

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    Stevens-Johnson Syndrome

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    Stevens-Johnson Syndrome Prodrome of malaise and fever, followed by the rapid

    onset of erythematous or purpuric macules and plaques

    Detachment of

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    Etiology of SJSEtiology

    Infections (herpesvirus, Mycoplasma pneumoniae)

    Neoplastic and autoimmune diseases

    Medications(sulfonamide antimicrobials, phenobarbital,carbamazepine, lamotrigine, acetaminophen/paracetamol,valproic acid, NDAIDs)

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    Management of SJS Removal of any possible offending agent

    Supportive care

    Wound care

    Nutritional support

    Ocular care

    Prevention of infection

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    Management of SJS Adjunctive therapies

    Glucocorticoids

    IVIG

    Cyclosporine

    Plasmapheresis

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    Prognosis of SJS Long-term Sequlae

    Scarring, irregular pigmentation, eruptive nevi,

    abnormal re-growth of nails, and alopecia

    Dry eye, photophobia, visual impairment, ingrowneyelashes (trichiasis), neovascularization of the cornea,keratitis, and corneal scarring leading to blindness

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    Case ContinuedStarted on Acyclovir for possible VZV

    Started on Azithromycin for possible mycoplasma

    Dermatology consult with biopsyTreated with IVIG

    Further laboratory evaluation

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    Case Continued Laboratory:

    HSV PCR (plasma and lip lesion): negative

    HSV DFA (lip lesion): negative VZV IgM: 5.4, VZV IgG: 2.5

    VZV culture (lip lesion): negative

    Mycoplasma IgM: 5.84, IgG: 3.72

    EBV IgM: neg, IgG pos Skin Biopsy: Interface reaction (with Civatte bodies) that is

    consistent with either Erythema Multiforme, Stevens-JohsonSyndrome, or TEN

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    References

    Wetter and Camilleri. Clinical, etiologic, and histopathologicfeatures of Stevens-Johnson Syndrome during an 8-year periodat Mayo Clinic. Mayo Clin Proc. 2010;85(2):131-138.

    Levi et al. Medications as risk factors of Stevens-Johnson

    Syndrome and Toxic Epidermal Necrolysis in Children: a pooledanalysis. Pediatrics. 2009;123(2):297-304.

    Metry et al. Use of intravenous immunoglobulin in children withStevens-Johnson Syndrome and Toxic Epidermal Necrolysis:seven cases and review of the literature. Pediatrics.2003;12:1430-1436.

    Pozzo-Magana et al. A systematic review of treatment of drug-induced Stevens-Johnson Syndrome and Toxic EpidermalNecrolysis in children. J Popul Ther Clin Pharmacol.2011;18(1):121-133.