Your Diagnosis, Please Edited by Parvin H. Azimi, MD
Fever, Rash, Lymphadenopathy and Painful Scab in an 11-year-old Girl Monica Nayakwadi-Singer, MD and Brian P. Lee, MD
A
previously healthy 11-year-old female presented to the emergency department with fever for 7 days, rash, enlarged lymph nodes and a painful scab on the top of her head. She lived in Portugal but had arrived in California in July with her sister and mother to visit relatives. They were staying at the home of an uncle and aunt in Clayton, California where there were also 2 dogs, 2 cats, several chickens, 2 goats and many deer roaming near the property. Six days after her arrival in the United States, the patient traveled by car to Lake Tahoe where she spent approximately 2 days at a campground during the daytime and swam in the lake, but slept the nights in a hotel. She then returned to her uncle and aunt’s home, and 4 days later (13 days after her arrival in the United States), she noticed a “bump” behind her right ear and painful swollen glands along the right side of her neck. The next day, she complained of pain over the top of her head, where her mother noticed 3 “black spots”. One of these fell off while the patient was combing her hair and looked like a “black scab”. The patient was evaluated at an urgent care clinic the following day and was treated with cephalexin for presumed lymphadenitis. Two days later (17 days after arrival in the United States), she began experiencing fevers up to 38.4°C despite antibiotic therapy. She returned to the same urgent care clinic, and trimethoprim/sulfamethoxazole was added to her treatment regimen. Although the fevers transiently improved, the patient complained of fatigue and continued to have lymph node swelling and pain on her scalp. Six days later, she began having higher fevers associated with chills, frontal headache and nonbilious, nonbloody emesis. She returned to the urgent care clinic where blood tests revealed a white blood cell count of 2.3 × 103/mm3 (with differential of 65% polymorphonuclear cells, 18% lymphocytes, 14% monocytes and 3% eosinophils), hemoglobin of 13 gm/dL and a plate-
Accepted for publication July 25, 2013. From the Division of Infectious Diseases, Children’s Hospital and Research Center at Oakland, 747 Fifty Second Street, Oakland, CA 94609. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose. Copyright © 2013 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3301-0114 DOI: 10.1097/INF.0000000000000013
114 | www.pidj.com
FIGURE 1. Two 3-mm dark brown eschars on the scalp and an adjacent 4 mm erythematous macule at the site of a previous eschar. let count of 168 × 103/mm3. She was referred to the Children’s Hospital & Research Center Oakland emergency department. In the emergency department, further history revealed that the patient was previously healthy and had no ill contacts, including no known exposure to tuberculosis. She denied ingestion of uncooked foods and unpasteurized dairy products, and she had not noticed any insect bites. She had a fever of 39.6°C, respiratory rate of 20 breaths/minute, heart rate of 114 beats/minute and blood pressures as low as 75/33 mmHg. Despite being tachycardic and hypotensive, she was well appearing and had an appropriate mental status. Her physical examination was significant for two 3 mm dark brown eschars on the superior parietal area of her scalp and an adjacent 4 mm erythematous macule at the site of a previous eschar (Fig. 1). She also had a 1 cm right posterior auricular lymph node and a 1.5 cm right cervical lymph node, both of which were nonerythematous, mobile and nontender. Shotty left cervical lymph nodes were also present. In addition, the patient had a petechial rash involving both popliteal fossae, the right arm, the dorsum of the right hand and both ankles but sparing the soles of her feet. No purpura or ecchymosis was noted. A II-III/VI harsh systolic murmur was heard along both the right and left sternal borders. No rub or gallop was appreciated. Abdominal examination showed no hepatosplenomegaly. The remainder of her examination was normal.
Her laboratory evaluation revealed white blood cell count of 1.7 × 103/mm3 (with differential of 59% neutrophils and 26% lymphocytes, 11% monocytes and 3% eosinophils), hemoglobin of 13.4 gm/dL and platelet count of 173 × 103/mm3. Absolute neutrophil count was 1003/mm3. Erythrocyte sedimentation rate was 15 mm/h, and C-reactive protein was 2.4 mg/dL. A compete metabolic panel was normal except for sodium concentration of 133 meq/L. Coagulation panel was abnormal with prothrombin time of 18.8 seconds (normal: 12.7–16.1 seconds), partial thromboplastin time of 39.8 seconds (normal: 28.8–39.2 seconds) and international normalized ratio of 1.5 seconds. A throat swab was negative for group A streptococcus by rapid antigen testing, and a lumbar puncture revealed a normal cerebral spinal fluid profile. In addition, serologic testing for EpsteinBarr virus, Borrelia burgdorferi, Franciscella tularensis, Anaplasma phagocytophilum and Ehrlichia chaffeensis, were negative. Parvovirus polymerase chain reaction of the blood was negative. An echocardiogram revealed normal cardiac anatomy and function and the absence of vegetations. The patient was given three 1 L boluses of normal saline and was admitted to the Pediatric Intensive Care Unit. A diagnostic test was performed that revealed the etiology of her illness. For denouement see p. 119
The Pediatric Infectious Disease Journal • Volume 33, Number 1, January 2014
Fever, Rash, Lymphadenopathy and Painful Scab in an 11-year-old Girl Monica Nayakwadi-Singer, MD and Brian P. Lee, MD
A
previously healthy 11-year-old female presented to the emergency department with fever for 7 days, rash, enlarged lymph nodes and a painful scab on the top of her head. She lived in Portugal but had arrived in California in July with her sister and mother to visit relatives. They were staying at the home of an uncle and aunt in Clayton, California where there were also 2 dogs, 2 cats, several chickens, 2 goats and many deer roaming near the property. Six days after her arrival in the United States, the patient traveled by car to Lake Tahoe where she spent approximately 2 days at a campground during the daytime and swam in the lake, but slept the nights in a hotel. She then returned to her uncle and aunt’s home, and 4 days later (13 days after her arrival in the United States), she noticed a “bump” behind her right ear and painful swollen glands along the right side of her neck. The next day, she complained of pain over the top of her head, where her mother noticed 3 “black spots”. One of these fell off while the patient was combing her hair and looked like a “black scab”. The patient was evaluated at an urgent care clinic the following day and was treated with cephalexin for presumed lymphadenitis. Two days later (17 days after arrival in the United States), she began experiencing fevers up to 38.4°C despite antibiotic therapy. She returned to the same urgent care clinic, and trimethoprim/sulfamethoxazole was added to her treatment regimen. Although the fevers transiently improved, the patient complained of fatigue and continued to have lymph node swelling and pain on her scalp. Six days later, she began having higher fevers associated with chills, frontal headache and nonbilious, nonbloody emesis. She returned to the urgent care clinic where blood tests revealed a white blood cell count of 2.3 × 103/mm3 (with differential of 65% polymorphonuclear cells, 18% lymphocytes, 14% monocytes and 3% eosinophils), hemoglobin of 13 gm/dL and a plate-
Accepted for publication July 25, 2013. From the Division of Infectious Diseases, Children’s Hospital and Research Center at Oakland, 747 Fifty Second Street, Oakland, CA 94609. E-mail: [email protected]. The authors have no funding or conflicts of interest to disclose. Copyright © 2013 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3301-0114 DOI: 10.1097/INF.0000000000000013
114 | www.pidj.com
FIGURE 1. Two 3-mm dark brown eschars on the scalp and an adjacent 4 mm erythematous macule at the site of a previous eschar. let count of 168 × 103/mm3. She was referred to the Children’s Hospital & Research Center Oakland emergency department. In the emergency department, further history revealed that the patient was previously healthy and had no ill contacts, including no known exposure to tuberculosis. She denied ingestion of uncooked foods and unpasteurized dairy products, and she had not noticed any insect bites. She had a fever of 39.6°C, respiratory rate of 20 breaths/minute, heart rate of 114 beats/minute and blood pressures as low as 75/33 mmHg. Despite being tachycardic and hypotensive, she was well appearing and had an appropriate mental status. Her physical examination was significant for two 3 mm dark brown eschars on the superior parietal area of her scalp and an adjacent 4 mm erythematous macule at the site of a previous eschar (Fig. 1). She also had a 1 cm right posterior auricular lymph node and a 1.5 cm right cervical lymph node, both of which were nonerythematous, mobile and nontender. Shotty left cervical lymph nodes were also present. In addition, the patient had a petechial rash involving both popliteal fossae, the right arm, the dorsum of the right hand and both ankles but sparing the soles of her feet. No purpura or ecchymosis was noted. A II-III/VI harsh systolic murmur was heard along both the right and left sternal borders. No rub or gallop was appreciated. Abdominal examination showed no hepatosplenomegaly. The remainder of her examination was normal.
Her laboratory evaluation revealed white blood cell count of 1.7 × 103/mm3 (with differential of 59% neutrophils and 26% lymphocytes, 11% monocytes and 3% eosinophils), hemoglobin of 13.4 gm/dL and platelet count of 173 × 103/mm3. Absolute neutrophil count was 1003/mm3. Erythrocyte sedimentation rate was 15 mm/h, and C-reactive protein was 2.4 mg/dL. A compete metabolic panel was normal except for sodium concentration of 133 meq/L. Coagulation panel was abnormal with prothrombin time of 18.8 seconds (normal: 12.7–16.1 seconds), partial thromboplastin time of 39.8 seconds (normal: 28.8–39.2 seconds) and international normalized ratio of 1.5 seconds. A throat swab was negative for group A streptococcus by rapid antigen testing, and a lumbar puncture revealed a normal cerebral spinal fluid profile. In addition, serologic testing for EpsteinBarr virus, Borrelia burgdorferi, Franciscella tularensis, Anaplasma phagocytophilum and Ehrlichia chaffeensis, were negative. Parvovirus polymerase chain reaction of the blood was negative. An echocardiogram revealed normal cardiac anatomy and function and the absence of vegetations. The patient was given three 1 L boluses of normal saline and was admitted to the Pediatric Intensive Care Unit. A diagnostic test was performed that revealed the etiology of her illness. For denouement see p. 119
The Pediatric Infectious Disease Journal • Volume 33, Number 1, January 2014
