Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a new featured series on PEMBlog that will highlight some of those classic cases.
14 year old male with a history fo prior HSV skin outbreaks presents progressive skin lesions, ill appearance and altered mental status.
Sixteen days prior to arrival he sustained elbow abrasions after falling in a freshwater river. Two days later (14 days prior to arrival) he noted dot-like rashes to his elbows, knee, and lip. His primary care doctor prescribed acyclovir 12 days prior to arrival when the lesions appeared vesicular.
Subsequently he developed MCP swelling and progression of lesions as they developed bull, petechiae and erythematous streaking. He was then started on clindamycin 3 days prior to arrival.
On the day of presentation to the Emergency Department he had a fever of 103.8F, nausea and NBNB emesis. He also complained of lightheadedness and alteration in his gait and mental status were noted by his family.
BP 95/57 HR 150 RR 20 T 101.4F Sats97% on room air
General: alert, appropriate, no acute distress, answering questions
Skin: some yellow crusting with minimal serous drainage. Full detail of the lesions are shown below.
Neck: negative Kernig/Brudzinski sign
HEENT: vesicular lesion on right lower lip
Cardiovascular: tachycardia, cap refill 3 seconds
Respiratory: normal respirations, clear to auscultation
Musculoskeletal: no joint swelling, full range of motion
Gastrointestinal:soft, NT/ND, normal bowel sounds
Neurological: AOx3, no focal deficits, normal neuro exam
This ill-appearing patient eventually received 60 mL/kg NS, and was admitted to the intensive care unit. Pertinent labs included:
What is the diagnosis in this 14 year old male with a progressive rash and altered mental status?
B. Erythema Multiforme
C. Rocky Spotted Mountain Fever
D. Erysipelthrix rhusiopathiae
E. Mycobacterium marinum
B. Erythema Multiforme
The diagnosis was confirmed by skin biopsy. The patient was tested for and found to be negative for Ehrlichia, RMSF, Leptospira, HSV DFA (lesion) and HSV culture (lesion), HIV, and all cultures of blood/bullae fluid/AFB/Fungus/Urine. Primary HSV is unlikely despite some of the vesicular features of these lesions. The petechiae raises the possibility of RMSF / tick-borne illnesses. Though Meningococcemia fits with the septic picture in a teen the full clinical features do not match any one infectious agent. Erythema multiforme best explais his skin lesions with his recurrent HSV infections as a possible trigger, though it does not explain the shock presentation.