Dressing up as fever and a rash

Key Points

The Case

You are just entering the emergency department (ED) for a part-time shift when you grab your first chart. You enter the room and begin taking the history of a 15-year-old girl whose chief complaint is that she has a fever and rash. The patient's mother reports a 2-day history of fever. The rash developed 12 hours before arrival. She asks what this could be.

Her mother reports that her daughter's maximum recorded temperature was 38.28°C orally. The rash began on her arms and has spread to her face, chest, upper legs, and buttocks. She reports discomfort because the rash is itching.

The patient is an immigrant who moved from Mexico 4 months ago. She was seen in an outside clinic approximately 2 weeks after her arrival in the United States for school vaccinations and a tuberculosis (TB) skin test. Her purified protein derivative (PPD) test measured 28 mm on the follow-up visit.

At that time, the patient reported occasional cough, and a chest x-ray (CXR) performed during that visit revealed a left upper lobe infiltrate.

The patient was treated with azithromycin and started on isoniazid. She was referred to the TB clinic for further workup and treatment.

The girl was seen again in the TB clinic 3 months later. Sputum cultures were sent during this visit, and the patient was started on RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol). The entire family had negative PPD testing, and there were no known TB contacts.

The TB specialist reviewed the CXR from the primary care physician and agreed that the infiltrate was concerning for TB.

A repeat CXR at that time was negative, but given the patient's history and previous CXR results, the decision was made to begin 9 months of treatment.

Today

It's now approximately 3 weeks later, and the patient presents in the ED with this new-onset diffuse and pruritic rash.

Physical examination reveals a temperature of 36.94°C, a pulse of 88 beats per minute, blood pressure of 104/66 mm Hg, and a respiratory rate of 16 breaths per minute. Her height is 160 cm (25th-50th percentile) and weight is 60 kg (75th-90th percentile).

Generally, the patient is an alert and happy girl in no acute distress. The sclera are anicteric, and the pupils are equally round and reactive to light and accommodation.

There is no nasal discharge; the oropharynx is mildly erythematous without exudates; extraocular eye muscles are intact. The neck is supple without lymphadenopathy or masses.

The cardiovascular exam reveals a regular rate and rhythm without murmur, and the lungs are clear to auscultation bilaterally. The abdomen is soft with normoactive bowel sounds; it is nontender and nondistended, with no hepatosplenomegaly.

Her skin exam is notable for a diffuse erythematous maculopapular rash involving the face; ears; upper and lower extremities, including bilateral palms; and anterior and posterior trunk. Her initial complete blood count (CBC) returns with a white blood cell count (WBC) of 8.3 and polymorphonuclear neutrophils (PMNs) of 79% (lymphocytes, 9%; monocytes, 7%; and eosinophils, 5%).

Her liver function tests (LFT) are concerning for hepatitis (aspartate aminotransferase [AST], 249 [15-37 U/L], and alanine aminotransferase [ALT], 272 [8-36 U/L]). HIV testing is negative. RIPE therapy was held for concerns of a drug reaction or allergic reaction and transaminitis.

Rapid streptococcal test and throat culture are positive for beta hemolytic streptococcus.

The patient is admitted and treated with 1 dose of intramuscular benzathine benzylpenicillin and intravenous diphenhydramine, with significant improvement in the rash. She has a negative viral hepatitis panel and negative monospot.

Her LFTs remain stable over several days, and abdominal ultrasound is negative except for mild splenomegaly. You decide to continue to hold the RIPE therapy until the cause of her transaminitis is clearer. You discharge her with plans to follow her carefully as an outpatient.