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.

The Case

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.

Physical Examination

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:

WBC %Neut   Hgb Hct Plt
21.5 97%   15.2 43.6 170
Na K Cl CO2 BUN Cr
126 3.5 89 24 22 1.2

What is the diagnosis in this 14 year old male with a progressive rash and altered mental status?

A. Meningococcemia

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.


Heinze A, Tollefson M, Holland KE, Chiu YE. Characteristics of pediatric recurrent erythema multiforme. Pediatr Dermatol 2018; 35:97.

Weston WL, Brice SL, Jester JD, et al. Herpes simplex virus in childhood erythema multiforme. Pediatrics 1992; 89:32.