Presented by Samuel Lee, MD
A 3 year old African-American male is brought to the ED by his mother with a fever for six days, sore throat, and a rash on his chest. The patient had been seen by his PCP 3 days ago, diagnosed with scarlet fever, and started on amoxicillin.
Since then the fever has not subsided and the mother has noticed painful swelling and skin peeling over the patient’s lips, palms, soles, and genital area. The patient cries when walking and avoids placing weight on his soles. The mother denies any sick contacts. The patient does not have a cough, nausea, vomiting ,or diarrhea. He has been eating and drinking, and the mother states that he is still producing urine.
Past Medical History: multiple past ED visits for croup
Medications: Amoxicillin X 3 days
Social Hx: lives with mother and grandmother in an apartment
Birth History: Full term SVD
Vital Signs: BP 90/56, HR 136, RR 24, Rectal Temp 38.8, Oxygen Sat. 99% on Room air; weight 18 kg
General: The patient is sitting on his mother’s lap; awake and alert, good eye contact; cries if he is made to stand on his feet
HEENT: Atraumatic/normocephalic; PERRL, bilat conjunctival injection, no discharge. The peri-oral area is swollen and erythematous and the lips are cracked. There is pharyngeal erythema with no exudate, vesicles, or lesions seen. MMM. No LAD upon palpation. Neck is supple; there is no nuchal rigidity.
Resp: Lung sounds clear to auscultation. No wheezing/rales/rhonchi.
Chest: Sandpaper rash on chest and upper abdomen which is resolving per mother. No vesicles or lesions.
CV: RRR, no murmurs, rubs, or gallops; pulses 2+ and equal in all ext.
ABD: Soft, nontender/nondistended. Positive bowel sounds, no flank tenderness.
EXT: palms and soles are swollen, erythematous, tender to palpation. No vesicles or lesions present. Cap refill less than 2 sec.
GU: There is an erythematous rash and peeling skin on the groin and penis. Testes descended.
Neurological: Awake, alert; able to ambulate but cries when weight is placed on soles.
Impression: Three year old male with 6 day hx of fever and scarlitiniform rash, initially diagnosed as scarlet fever; Condition has not improved with amoxicillin. Now with conjunctival injection, erythema and skin peeling of lips, palms, and GU area.
CBC: WBC 10, Hemoglobin 11.2, Hematocrit 32.6, Platelets 328
Diff: Neutrophils 61%, Lymphocytes 22%, Monocytes 14%, Eosin 3%, Bands 1%
Electrolytes: Na 138, K 4.8, Cl 103, CO2 20, AG 15
BUN 5, Creatinine 0.4
UA: clear, yellow, Specific Gravity 1.016, pH 7.5, WBC 5-10, no RBC, Nitrite and LE negative; 0 bacteria
CXR: mild hyperinflation, no focal opacity
Rapid Strep test neg
EKG: NSR@100 bpm, no axis deviation, no PR prolongation, no QRS widening, no atrial or ventricular hypertrophy, no ST changes, no T wave inversions, no accessory waves or ectopic beats; no previous EKG available for comparison
1. Given this patient’s history and physical exam, what is the best definitive course of action?
a. Admit the patient for treatment and arrange for an echocardiogram
b. Continue supportive treatment as an outpatient and have the patient follow up in one week for an echocardiogram
c. Initiate antibiotic treatment for Urinary Tract infection and arrange for a voiding cystourethrogram
d. Advise the patient’s mother to continue with amoxicillin and follow up with her PCP in 2 days.
2. What is a serious complication of this patient’s diagnosis?
a. Development of meningitis in the next week
b. Coronary artery aneurysm and myocardial infarction
d. Rhabdomyolysis and acute renal failure
3. What is the definitive treatment for this patient’s condition?
a. IV fluid 20cc/kg bolus
b. Nitrofurantoin 2 mg/kg PO X 10 days
c. IVIG 2 mg/kg over 12 hrs, Aspirin 100 mg/kg/day divided qid
d. Acetaminophen 15 mg/kg
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