Case PresentationCase Presentation

M.Haghighi MDM.Haghighi MD

A woman in her thirties was well until A woman in her thirties was well until approximately 3 days before approximately 3 days before presentation in mid-autumn, when presentation in mid-autumn, when fevers up to 103°F (39.4°C) developed, fevers up to 103°F (39.4°C) developed, associated with a associated with a sore throat and sore throat and malaisemalaise. .

She took ibuprofen for her She took ibuprofen for her symptoms. On the day of symptoms. On the day of presentation, she awoke with a presentation, she awoke with a rashrash over her face, scalp, trunk, and over her face, scalp, trunk, and proximal extremities. proximal extremities.

The lesions were The lesions were pruritic and pruritic and tendertender, and associated with , and associated with headache and nausea. There was no headache and nausea. There was no cough, dysuria, vaginal discharge, or cough, dysuria, vaginal discharge, or chest, abdomen, or joint pain. chest, abdomen, or joint pain.

Past medical history Past medical history /Allergies/Allergies

She reported having had chickenpox She reported having had chickenpox as a child and was up-to-date on her as a child and was up-to-date on her immunizations. immunizations.

MedicationsMedications

She had taken ibuprofen for her She had taken ibuprofen for her symptoms, as above. symptoms, as above.

Epidemiological HistoryEpidemiological History

She worked in a healthcare setting, She worked in a healthcare setting, and had no pets or known sick and had no pets or known sick contacts. She traveled intermittently contacts. She traveled intermittently to a wooded area in Northern New to a wooded area in Northern New England to visit relatives. England to visit relatives.

There was no history of any unusual There was no history of any unusual skin contacts, or tick or other insect skin contacts, or tick or other insect bites. She did not smoke tobacco, bites. She did not smoke tobacco, drink alcohol, or use illicit drugs. drink alcohol, or use illicit drugs.

Physical ExaminationPhysical Examination

The patient appeared The patient appeared fatiguedfatigued and and uncomfortableuncomfortable. The temperature . The temperature was 96.6°F (35.9°C), blood pressure was 96.6°F (35.9°C), blood pressure 133/77 mm Hg, pulse 96 beats per 133/77 mm Hg, pulse 96 beats per minute, and respirations 20 breaths minute, and respirations 20 breaths per minute, with an oxygen per minute, with an oxygen saturation of 97% while breathing saturation of 97% while breathing ambient air. ambient air.

There were numerous discrete, There were numerous discrete, tender, tender, erythematous maculeserythematous macules, , less than 1 centimeter in diameter less than 1 centimeter in diameter with a 1-to-3 millimeter with a 1-to-3 millimeter pustular pustular centercenter, on the face, scalp, chest, , on the face, scalp, chest, back, inner thighs, and arms, and back, inner thighs, and arms, and one lesion on her palm. one lesion on her palm.

The physical examination was The physical examination was otherwise normal .otherwise normal .

StudiesStudies

The white blood cell count was 6,300 The white blood cell count was 6,300 cells/mmcells/mm³³, with 35% neutrophils, , with 35% neutrophils, 35% lymphocytes, 21% atypical 35% lymphocytes, 21% atypical lymphocytes, 6% monocytes, 2% lymphocytes, 6% monocytes, 2% eosinophils, and 1% basophils. eosinophils, and 1% basophils.

She felt worse the following day, with She felt worse the following day, with increasing headache and skin increasing headache and skin lesionslesions. On examination, the . On examination, the temperature was normal; the temperature was normal; the neck neck was supplewas supple, and examination of the , and examination of the skin revealed approximately 30 skin revealed approximately 30 pustules on an erythematous base. pustules on an erythematous base. The remainder of the examination The remainder of the examination was unchanged from the previous was unchanged from the previous day. She was admitted to the hospital. day. She was admitted to the hospital.

Additional test results included an Additional test results included an alkaline phosphatase of 154 U/L alkaline phosphatase of 154 U/L (reference range 30-100 U/L), (reference range 30-100 U/L), aspartate aminotransferase 42 U/L aspartate aminotransferase 42 U/L (reference range 9-32 U/L), alanine (reference range 9-32 U/L), alanine aminotransferase 47 U/L (reference aminotransferase 47 U/L (reference range 7-30 U/L), and total bilirubin range 7-30 U/L), and total bilirubin 0.3 mg/dl. 0.3 mg/dl.

A A lumbar puncturelumbar puncture was performed, was performed, and analysis of the cerebrospinal and analysis of the cerebrospinal fluid showed no white blood cells and fluid showed no white blood cells and normal levels of glucose and protein. normal levels of glucose and protein.

A chest radiograph and computed A chest radiograph and computed tomography of the brain were also tomography of the brain were also normal. An ultrasound of the normal. An ultrasound of the abdomen showed diffuse fatty abdomen showed diffuse fatty infiltration of the liver and the infiltration of the liver and the spleen size was normalspleen size was normal. .

The patient was seen by the The patient was seen by the dermatology service and a dermatology service and a skin skin biopsy was performedbiopsy was performed. .

Over the next two days, some lesions Over the next two days, some lesions evolved to become crusted with a evolved to become crusted with a central eschar .central eschar .