Address: Chiang Mai
CC: fever for 4 days and a skin rash
on admission day
PI: He had been healthy until 4 days ago
he had gradual onset of high fever. On the third day of fever he was taken
to see a doctor at the OPD. He was seen in the OPD once, on day 2 of fever
with the diagnosis of "probable urinary tract infection". Because
or his persistent fever he was brought again to see the doctors at the
OPD. At the OPD, other than fever he had no other localizing sign. The
CBC show: Hb 7.3 gm% Hct 23.7% WBC 5,200/cbmm, platelet count 147,000/cbmm.
U/A : yellow clear , pH 5.5 , sp.gr. 1.010 , RBC 0-1 , WBC 5-7 , epithelium
3-5. While waiting for the result of urine culture he was sent home with
norfloxacin orally. On the next day (the day of admission) his mother
observed that he developed rash at his trunk and extremities mainly at
left goin and both thighs. The rash was more predominant when he had high
fever. She also noticed that he could not stand up or walk as usual.
Past History: was unremarkable.
Significant PE: fully conscious, but irritable.
BW 10 kg, T. 40.2 C., HR 120 beats/min, RR 24 /min, BP 90/50 mmHg,
HEENT : Mildly pale conjunctiva , no icteric sclera , no injected pharynx
, no strawberry tongue , tympanic membranes were intact both sides.
Heart : Regular rhythm , no murmur.
Lungs: Clear , no adventitious sound.
Abdomen : Soft , no tenderness , no organomegaly.
Extremities: he flexed his left hip joint
and had limited range of motion.
SKIN: erythematous maculopapular rash at the skin
as shown in the figure 1. The rash started at left inguinal region, spread
within less than 24 hours to the body, face and extremities. Some part
of the rash was later covered with small vesicles as shown in the figure.
Initial laboratory investigations:
CBC: Hb 8.8 gm%, Hct 27%, WBC 10,800/cbmm (N 83%,
L 179%), platelet count 346,000/cbmm.
PBS : Hypochromic microcytic RBC , toxic granulation 1+, vacuolization
1+
Reticulocyte count : 0.3%
U/A : Yellow clear , sp.gr. 1.015 , pH 5.5 , no WBC , no RBCUA: WNL
BUN/Cr : 8/0.5
Electrolytes : Na 130 K 5 Cl 96 Total CO2 16
SI/TIBC : 13/178
Nicking of the superficial small vesicles: no organism
found
Figure 3 Temperature chart
He was started on cloxacillin intraveniously on admission. On the fourth day of admission, although the fever persist, the rash subsided and a 3x6 cm. subcutaneous fluctuated mass could be palpable at the left inguinal region. Needle tapping under U/S guide was done and obtained yellowish pus. The I/D was done and obtained 30 cc of pus. Gram stain of the pus is shown in figure 2.
Figure 2 Gram stain of the pus
Pus culture: Staphylococcus aureus
Figure 4 Peeling of the skin
2. Iron deficiency anemia
The rashed in Figure 1 has been called erythematous rashes or scarlet fever-like rashes or scarlatiniform rashes or scarlatiniform exanthem or a confluent erythematous sandpaper-like rash. It is characterized by very small, often confluent, red papules, and typically occurs on the trunk and extremities. The skin may feel rough, like fine sandpaper.
Possible Etiologies include;
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> Scarlet fever |
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> Staphylococcal scarlet fever |
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> Drug or other allergy |
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> Erythema infectiosum or Fifth disease (Parvovirus B19 infection) |
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> Kawasaki disease |
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> Toxic shock syndrome |
Each etiology has its own characteristics. Further reading in any standard text book is suggested.
