Index of Suspicion

Abstract

* ALT: : alanine aminotransferase AST: : aspartate aminotransferase BUN: : blood urea nitrogen CBC: : complete blood count CNS: : central nervous system CSF: : cerebrospinal fluid CT: : computed tomography ECG: : electrocardiography ED: : emergency department EEG: : electroencephalography ESR: : erythrocyte sedimentation rate GI: : gastrointestinal GU: : genitourinary Hct: : hematocrit Hgb: : hemoglobin MRI: : magnetic resonance imaging WBC: : white blood cell A 2-year-old white girl presents with a 2-month history of a rash around her mouth and nose. On examination, she has perioral and perinasal pink papules and papulopustules, which coalesce to form thin plaques, as well as occasional periorbital papules and a small area of crusting in the perinasal region (Fig 1). The rash is nonpruritic but accompanied by a burning sensation. Notably, the patient’s vermilion border is spared. Figure 1. Perioral and perinasal pink papules and papulopustules that have coalesced to form thin plaques, occasional periorbital papules, and a small area of crusting in the perinasal region. Her past medical history is significant for a congenital cystic adenomatoid malformation (surgically resected at 6 weeks of age), atopic dermatitis, seasonal rhinitis, and asthma, requiring fluticasone propionate (44 mcg/puff twice daily) via a metered dose inhaler with spacer and face mask for the past 6 months (Fig 2). The dermatitis has been treated with over-the-counter cream and ointment without relief, but no topical products containing hydrocortisone have been used. The patient is seen by a dermatologist for the cause of the persistent facial rash, and her history and findings on physical examination lead to a presumptive diagnosis. Figure 2. Patient using metered dose inhaler with spacer and face mask. A 2-year-old boy presents with a history of seizures since the age of 9 months. The first episode started as a febrile seizure and led to status epilepticus. He was diagnosed as having generalized epilepsy of unknown origin after evaluation by a neurologist and EEG. The seizure activity initially was generalized and tonic-clonic in nature. He would drop and exhibit jerking movements of the arms and legs, followed by generalized tonic posturing, accompanied also by rolling back of the eyes, drooling, and oral cyanosis. Recently, however, his seizures have consisted of myoclonic jerks, mainly of the …