2 yo with Fever

and Rash
Erin 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.
Exam

VS: Temp 37.6, HR 155, RR 35, BP 101/67 (78), SpO2 normal on RA
GENERAL: 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 abnormalities
GENITOURINARY: 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
Sweets syndrome
Poison Ivy
Erythema
multiforme
CV:
Kawasakis
Heme/Onc
HLH
Lymphoma
ID
CMV
EBV
Scarlet fever/Strep
Lyme Disease
2/2 syphilis
HIV
HSV
Rheum/Misc:
Lupus
JIA
Dermatomyositis
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
Carbamazepine
Lamotrigine
Phenytoin
Sulfasalazine
Vancomycin
Minocycline
Daopsone
Sulfamethoxazole
Sulfas in general

DRESS
Images 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.html
UpToDate. Drug Reaction with Eosinophilia and Systemic
Symptoms (DRESS). Roujeau, Jean-Claude.
UpToDate. Approach to dermatologic dianosis. Goldstein,
A.O.; Goldstein, B.G..
Visual dx
Google Images