Diagnosing a Rash
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Transcript of 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.