This is the second of three exclusive PEMPix cases that will be posted online in advance of the 2019 Section on Emergency Medicine programming at the American Academy of Pediatrics National Conference and Exhibition.

This case was originally submitted by…

Emily Hegamyer, MD

Third Year Pediatric Emergency Medicine Fellow
Nemours Alfred I. duPont Hospital for Children
Wilmington, DE

The Case

A 12 year old female presents with a rash that has been present for ten days. She first noted a blister on her right foot after walking barefoot outside, with subsequent spread to her back, bilateral arms and both feet. Initially the rash was mostly itchy, but now it is now painful as well. The blisters continue to grow larger with the addition of small, reddish bumps on her arms, legs and back.  She was evaluated by her primary care doctor two days ago and was prescribed cetirizine and trimethoprim/sulfamethoxazole which she has taken for two days with no improvement.  She does note that she has been both slightly dizzy, and a little more sleepy since starting these medications. 

Review of Systems

Constitutional: Negative for appetite change, fatigue or fever.
HEENT: Negative forcongestion, rhinorrhea, eye pain, eye redness, sore throat.
Respiratory: Negative for cough or shortness of breath.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria, hematuria, urinary frequency. 
Musculoskeletal: Negative for myalgias, arthralgias.  uSkin: Positive for rash.
Neurological: Positive for light-headedness. Negative for syncope and headaches. 

Physical Examination

VITALS: BP 121/66 | Pulse 97 | Temp 36.9 °C (98.4 °F) | Resp18 | Wt45.3 kg (99 lb13.9 oz)
Constitutional: Patient in no acute distress.  Appropriately interactive.  Appears well-nourished and well-developed. 
Head:  Atraumatic.  No cranial deformities noted.  
Nose:  Nares patent.
Mouth/Throat: Mucous membranes are moist, non erythematous.   No pharyngeal erythema, edema or tonsillar exudate.
Eyes: PERRLA.  EOM intact.  Conjunctivae normal.  No eye discharge noted. No scleral injection or icterus.
Neck: Normal range of motion.  Neck supple.
Cardiovascular: Regular rate and rhythm. S1 normal and S2 normal.  No murmurs, rubs or gallops.  2+ DP b/l.  Cap refill <3s.
Pulmonary/Chest:  Breathing comfortably.  Good air movement throughout lung fields b/lwith no wheezes/rales/rhonchi.  No accessory muscle use or nasal flaring.
Abdominal: Soft.  No distension.  Non-tender to palpation in all four quadrants with no rebound tenderness or guarding.  No hepatosplenomegaly appreciated.
Genitourinary:  Normal phenotypic female.  No erythema, edema, blisters, vesicles, pustules or rash noted in genital region.
Musculoskeletal: Normal range of motion in upper and lower extremity joints. She exhibits no edema or deformity in upper or lower extremities.
Neurological:  CN II-XII intact.  Strength 5/5 in UE/LE b/l.  Sensation intact in UE/LE b/l.  Normal muscle tone and bulk.
Skin: Skin is warm and dry. No petechiae, no purpura. No cyanosis. No mottling.  Several blisters of varying sizes noted on bilateral feet and hands with underlying erythema and mild edema, particularly on dorsal aspect of right foot.  Yellowish drainage noted between 2nd and 3rd toe of right foot in area where blister had been unroofed.  Diffuse maculopapular erythematous rash on upper and lower extremities with scattered pinpoint blisters.  No involvement of chest, back, face or genital region.  Large blisters are particularly tense to touch and extremely tender to palpation.  

The images seen below are courtesy of Emily Hegamyer, MD, 2019



What is the diagnosis?

A. Bullous pemphigoid

B. Fixed drug eruption

C. Epidermolysis bullosa

D. Bullous impetigo

E. Autoeczematization



E. Autoeczematization

Ultimately, this patient had a dermatophyte (tinea) infection with overlying hypersensitivity/Id reaction. This is a type of dyshidrotic eczema (usually of the hand/foot) characterized by vesicles/bullae. It may be triggered by inflammatory dermatophyte infections. The Id reaction (autoeczematization) is basically a widespread eczematous eruption in response to a distal focus of infection. Common manifestations include a papulovesicular eruption with vesicles on the hands and feet secondary to a fungal infection (dermatophytid). This young lady acquired tinea pedis while walking outside barefoot.

She was treated with a smaller dose of cetirizine 1/2 tab daily (since the bigger dose made her dizzy and sleepy), terbinafine 250mg daily x 30 days, and topical application of clotrimazole cream daily to the blisters on hands and as well as to her feet/under and between the toes.

One month later she noted an improved appearance of the rash, and greatly reduced symptoms.


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