2 yo with Fever and

RashErin Fuchs, MD PGY3

Morning Report July 2, 2014

HPI• 2 year old • Presents with h/o 9 days of fever • 3 days PTA developed a diffuse rash• PTA had been seen by PCP twice and ED twice• PCP dx with AOM and started on Amoxicillin.

• Received ~ 5 days, but developed rash• Switched to Cefdinir.

• Received 1 days worth prior to presenting to ED

HPI• Over the last 2 days she has had significant

decrease in PO intake • ED: Normal course• Admitted to RTU 2/2 to lack of PO intake• Transferred to floor next morning for fever,

rash, and poor PO intake

Background• PMH:

• Recurrent UTIs – evaluated by Urology and normal, but had received numerous different ppx antibiotics including Nitrofurantoin, Bactrim, Amoxicillin, and Cefdinir

• Meds: Omnicef x1 day• UTI ppx: Started back on Nitrofurantoin 1 month ago.

• With illness, Nitro stopped and started on Amox (~5days).

• Allergies: NKDA• Imms: UTD

Background• Diet: Normal• SHx: Lives at home with parents, brother,

uncles, and cousins (8 people total at home). • Dad – works in house cleaning• Mom – stays at home• No daycare.• Brother recently sick with a throat infection

• FHx: Negative for autoimmune• ROS: dec PO, stomach/body/leg pain, fever,

rash, ?swollen cheeks, pruritis.

ExamVS: Temp 37.6, HR 155, RR 35, BP 101/67 (78), SpO2 – normal on RAGENERAL: Young girl in obvious distress/discomfort laying in bed crying. HEAD: normocephalic, atraumatic.EYES: normal pupillary reflexes bilaterally, extraocular movements intact, no conjunctival injection.EARS: right tympanic membrane gray, normal light reflex and landmarks, no effusion or perforation, tympanic membrane on left injected and erythematous.NOSE: crusted dried nasal discharge, no obstruction.OROPHARYNX: dry mucus membranes, no pharyngeal erythema, no oropharyngeal lesions, tongue white and dry, lips without cracks.NECK: supple, shotty cervical lymphadenopathy.

CARDIOVASCULAR: tachycardic, normal rhythm, normal S1/S2, no murmur, pulses mildly bounding.LUNGS: clear to auscultation bilaterally, good air flow, no retractions, no wheezing, no crackles.ABDOMEN: soft, non-tender, non-distended with active bowel sounds and no masses or hepatosplenomegaly.EXTREMITIES: all extremities warm and well perfused, no cyanosis.BACK: no gross abnormalitiesGENITOURINARY: Tanner Stage 1 female genitalia.NEUROLOGIC: awake and alert, grossly normal strength, normal tone.SKIN: diffuse macularpapular confluent erythematous rash covering body (head, scalp, arms, chest, trunk, back, hands, feet, and genitalia - spares palms) warm to touch, non-blanching, no mottling, no jaundice, no unusual birthmarks

Differential Diagnosis• Derm

• SJS/TEN• DRESS• Drug reaction• Viral exanthem• Atopic

dermatitis• Sweet’s

syndrome• Poison Ivy• Erythema

multiforme

• CV:• Kawasaki’s

• Heme/Onc• HLH• Lymphoma

• ID• CMV• EBV• Scarlet

fever/Strep• Lyme Disease

• 2/2 syphilis• HIV• HSV

• Rheum/Misc:• Lupus• JIA• Dermatomyositi

s• Sunburn• Sezary

Syndrome

Work-Up• VRP negative• CMP: Na 136, K 4.3, CL 107, CO2 17, BUN 8, Cr 0.27, Glu 90, Ca

9.0, Protein 6.8, Albumin 3.0, Bilirubin 0.3, Alk Phos 325, ALT 345, AST 245

• CRP 2.5; ESR 46• CBC: WBC 12.1, Hgb 11.3, Hct 32.9, Plt 323; 13B, 18N, 60L, 9M,

0E• UA: Cath -- SG 1.015, pH 6.5, Glucose negative, Ketones trace,

Nitrite negative, Hemoglobin negative, Protein negative, LCE negative, WBC 3, Bacteria negative.

• CXR: Viral• UCx and BCx: <1000 organisms and negative

Diagnosis• CBC: WBC 10.4, Hgb 10.7, Hct 31.6, Plt 303;

13B, 1E, atypical lymph+• CMP: Na 135, K 4.0, Cl 109, CO2 17, BUN 2,

Cr .3, Gluc 127, Ca 97, Prot 7.8, Alb 3.4, Bili 0.2, Alk Phos 295, ALT 152, AST 76

• EBV:• VCA IgM: Positive• EA IgG: Negative• VCA IgG: Equivocal• NA ABS: Negative

Infectious Mono + Amox Rash

• No Previous Infection           VCA IgM: Neg          EA IgG:  Neg          VCA IgG: Neg          NA ABS : Neg

• Acute Infection           VCA IgM: Pos          EA IgG: Pos or Neg          VCA IgG: Pos          NA ABS : Neg

• Recent Infection           VCA IgM: Pos or Neg          EA IgG:  Pos or Neg          VCA IgG: Pos

          NA ABS : Pos      

• Persistent/Reactivated Infection           VCA IgM: Neg          EA IgG:  Pos          VCA IgG: Pos          NA ABS : Pos or Neg      

• Past Infection           VCA IgM: Neg          EA IgG:  Neg          VCA IgG: Pos          NA ABS : Pos

Drug Reaction w/ Eosinophilia &Systemic Symptoms DRESS

• Incidence unknown• High Morbidity• 10-20% no drug identified• Clinical:

• 2-6wks after exposure to med• Fever, malaise, lymphadenopathy, skin eruption• Starts as a mrbiliform eruption and progresses to diffuse,

confluent, infiltrated erythema with follicular accentuation• Involves >50% BSA and/or includes 2 or more:

• Facial edema (50% cases)• Infiltrated lesions• Purpura• Scaling (10-20%)

Drugs• Allopurinol• Carbamazepi

ne• Lamotrigine• Phenytoin• Sulfasalazine

• Vancomycin• Minocycline• Daopsone• Sulfamethoxazo

le• Sulfas in

general

DRESSImages of

Drug Reaction with Eosinophilia & Systemic Symptoms

f

What to look for

• Organ involvement (90%):• Liver – elevated LFTs

(HM, jaundice)• Severe hepatitis ->

majority of deaths• Kidney – Acute

interstitial nephritis• Lung – nonspecific

symptoms• CXR/CT – interstitial

pneumonitis and/or pleural effusions

• Heart, GI, Pancreas, Thyroid, Brain, Muscle, Peripheral nerves, Eye

• Abnormal Labs:• Leukocytosis

w/ eosinophilia• Atypical

lymphs• Increased LFTs• HHV-6 (Parvo)

+

Resolution• Withdrawal of drug• Gradual improvement

• Average time 6-9 weeks• Up to 20% can persist for several

months with remissions and relapses

Derm Terms Refresher

• Macule – non-palpable, flat, vary in pigmentation, <1cm

• Patch – non-palpable, flat, vary in pigmentation, >1cm

• Papules – Palpable, discrete lesions, <5mm

• Plaques – Palpable, flat, lesions >5mm

• Nodules – palpable, discrete lesions, >6mm

• Pustules – small, circumscribed papules w/ purulent material

• Vesicles – small (<5mm), circumscribed papules w/ serous material

• Wheals – irregularly elevated edematous skin areas – often erythematous

Resources“Drug Hypersensitivity Syndrome.” Dermnet NZ. http://dermnetnz.org/reactions/drug-hypersensitivity-syndrome.htmlUpToDate. “Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS).” Roujeau, Jean-Claude.UpToDate. “Approach to dermatologic dianosis.” Goldstein, A.O.; Goldstein, B.G..Visual dxGoogle Images