Fever with diffuse macular erythroderma in a 20-month-old boy (Page 1/1)
Prepared by...
Virat Sirisanthana, M.D. *
* Department of Pediatrics, Chiang Mai University
 
History:
CC:A 20-month-old previously healthy male child had a 2-day history of acute onset of high fever,
generalized erythroderma and diarrhea. One day prior to admission he developed generalized
tonic clonic colvulsion with alteration in consciousness.
On admission he developed shock which needed 24 hours of intensive care measures.
 
PE:
GA: consciousness was drowsy to semi-coma and he was on intubation.
VS: BP (50/20…. 85/28 mmHg), Temp. 39.5 C, P 130 beats/min RR 40 breath/min.
Skin and soft tissue: generalized erythroderma, maculopapular rash with some spots of petichial
rash. A 2-cm in diameter subcutaneous mass was palpable at right anterior axillary region. It was
movable and not fluctuated. Tenderness of the mass could not be accessed.
HEENT: no evidence of rhinitis, otitis, or conjunctivitis.
Chest: no wheeze, air exchange is good
Cardiovascular: normal heart sounds, no murmur
Abdomen: liver 3 cm. below RCM, spleen not palpable
Nervous System: consciousness was drowsy to semi-coma
DTR: 1+ all, babinski: negative
clonus :negative, no stiff neck
 
Initial laboratory findings:
CBC: hemoglobin: 9.3 mg, hematocrit: 31 % , WBC: 15,200 cells/cu.mm (with 83 % neutrophils,  6% band forms, 10 % lymphocytes and 1% eosinophil), platelet count: 96,000 cells/cu.mm.
LP: CSF examination : clear, no WBC, RBC 100 cells/cu.mm, protein 38 mg%, sugar 66 mg%
(BS 83 mg%).
C.S.F. latex agglutinin test were negative for Hemophilus influenzae type b andS. pneumoniae.
 
Summery of the course of this patient from day 1 of signs and symptoms:
 

fever day 1 - day 8
 

hypotension day 3
  rash : 
 
erytroderma day 1- day 6
maculopapular, petichiae day 3 - day 5
desquamation day 7 - day 15
  organs system involvement: 
 

 

 

 GI tract involvement(watery diarrhea) day 1- day 4
CNS (alteration of conciousness without focal neurological sign) day 3 - day 6 (no hypotension)
renal (increase of creatinine) day 3 - day 5
  right anterior axillary mass     (no ticeday 3) => abcess day 6
fig-1.jpg (44819 bytes)
fig-2.jpg (36629 bytes)
   
Figure 1.  Abcess at right anterior axilla
Figure 2.  Desquamation day 7
 
Other laboratory findings:
  blood culture : no growth
C.S.F. culture : no growth
pus from right anterior axillary mass culture => Staphylococccal aurreus
serum eletrolyte: sodium 112 -> 130, potasium 4.3, chloride 89, bicarbonate 12
renal function: BUN 29 creatinine 1.0
LFT total protien 4.2, (albumin 2.5 globulin 1.7), SGOT 60, SGPT 60, cholesterol 41, alkaline phosphatase, total bilirubin 3.02, direct bilirubin 2.72
 
Summery of the outcome:
The patient received supportive, symptomatic and anti-Staphylococcus drugs. He gradually recovered and was discharged home.
 
Diagnosis : Staphylococcal Toxic Shock Syndrome
 
fig-1.jpg (47167 bytes)
 
Major systemic skin and mucous membrane manifestations of TSS (from ref. 1)
 
     The case definition established by the Centers for Disease Control and Prevention (USA) is based on the following five major diagnostic criteria (ref. 2):
>
 Fever of 38.9 C (102 F) or higher
>
 Presence of a diffuse macular erythroderma
>
 Desquamation 1 to 2 weeks after the onset of illness, particularly of the palms and soles
>
 Hypotension, defined as a systolic blood pressure of 90 mm Hg or less for adults and less than the fifth percentile for children younger than 16 years; an orthostatic decrease in diastolic blood pressure of 15 mm Hg or more with a position change from lying to sitting; orthostatic syncope; or orthostatic dizziness
>
 Involvement of three or more of the following organ systems: gastrointestinal tract, muscular, mucous membrane, renal, hepatic, hematologic, and central nervous system.
 
     In addition, if blood and cerebrospinal fluid cultures are obtained, they must be sterile, with the only exception that blood cultures may be positive for Staphylococcus aureus. Serologic tests for Rocky Mountain spotted fever, ehrlichiosis, leptospirosis, and measles also, when obtained, must be negative.   
 
     Toxic shock syndrome is probable when at least four of the five major criteria arefulfilled.
Patients who die before desquamation would have occurred but whose ill-ness is otherwise
compatible with TSS are considered definite cases. The syndrome can be confused with Kawasaki
disease, scarlet fever, Rocky Mountain spotted fever, ehrlichiosis, meningococcemia, measles,
leptospirosis, and other febrile diseases with mucocutaneous manifestation and/or hypotension.
Telogen effluvium, including hair thinning or patchy hair loss, and nail splitting, ridging, or loss,
frequently occur 1 to 2 months after onset. Neuropsychologic sequelae can occur but appear to be
infrequent.
 
Further Readings:
1.
 Chesney PJ, Denise JP, Purdy WK, et al. J.A.M.A.1981:246:741-8.
2.
 American Academy of Pediatrics. Staphylococcal toxic shock syndrome. In: Peter G, ed. 1 997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL:American Academy of Pediatrics; 1997:481-2.

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