PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s visual diagnosis competition. It is held annually at the National Conference and Exhibition. This year, all ten finalists will be posted online on PEMBlog.com and at PEMPix.com, one a day with voting opening to AAP Section on Emergency Medicine members thereafter. I hope you enjoy this online-only format, and hope that it will serve to highlight some of the fantastic learning cases that our colleagues submitted this year. It was again very difficult for the panel of judges to select the finalists and I could not have done it without their assistance. As a special treat I’ve included a musical selection form the 1980s as an optional “hint,” and to serve as a soundtrack for your learning.
This PEMPix case was submitted by:
Joseph Shapiro, MD, a Clinical Associate from Children’s National Hospital in Washington, DC
That looks really bad…
A 7 year-old previously healthy boy with 3 weeks of progressive painful rash and fevers presented to the Emergency Department. One month ago he was also ill and positive for influenza A by rapid antigen – he recovered, then approximately a week later developed the rash and fever. His primary care doctor saw him early in the course of the rash a prescribed a 10-day course of cephalexin, which the patient completed, and the symptoms seemed to improve (fevers resolved). The symptoms soon returned with a vengeance and the rash dramatically worsened. The rash itself was initially sparse with reddish-brown papules across the body, face, extremities, and external genitals. Mucosal surfaces were spared. Eventually the papules became too numerous to count and formed necrotic ulcerative confluences as shown in the image below.
In the Emergency Department he was febrile to 38.1 degrees Celsius, tachycardic to 128 beats/minute, and ill- appearing. Initial labs were notable only for CRP of 6.83 mg/dl. CBC, CMP, & urinalysis were within normal limits. Here is the aforementioned rash.
