Visual Diagnosis: A 15-year-old Female Who Has Cough, Rash, and Painful Swallow

Abstract

1. Laura K. Bullen, MD* 2. Joseph A. Zenel, MD* 1. *Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, Ore A 15-year-old female was in good health until 2 weeks ago, when she developed a mild cough, sore throat, and rhinorrhea. One week ago, her physician diagnosed acute right otitis media and bronchitis and treated her with amoxicillin/clavulanate. Over the past 24 hours, she has developed a painful, itchy rash on her face and trunk, blisters in her mouth, and difficulty drinking. She has had no fevers, vomiting, diarrhea, dysuria, or hematuria. She complains of vague abdominal pain. She has taken no other medications besides the antibiotic and has had no exposures to other medicines or toxins. On physical examination, she displays significant discomfort and frequently wipes spit from her mouth. Her weight is 60 kg (75th percentile), temperature is 97.3°F (36.4°C), pulse is 98 beats/min, respiratory rate is 20 breaths/min, and blood pressure is 106/64 mm Hg. Her oxygen saturation on room air is 97%. Eye examination reveals conjunctival injection and marked yellow discharge (Fig. 1). Her lips are dry and cracked, with sloughing of her buccal mucosa (Fig. 2). Chest auscultation reveals rhonchi and diffuse crackles in both lungs. Cardiac examination shows normal S1 and S2 heart sounds and no murmur. Her abdomen is soft with normal bowel sounds and no tenderness, masses, or organomegaly. She has multiple lesions on her trunk and face that consist of erythematous macules that have necrotic or vesicular centers (Fig. 3). Several small vesiculopapules with surrounding erythema are scattered over her extremities (Fig. 4). The remainder of her examination is within normal limits. Figure 1. Conjunctival injection with purulent discharge. Note vesiculopapule on nose. Figure 2. Red, cracked lips. Figure 3. Asymmetric erythematous macule with separate necrotic and vesicular centers on abdomen. Figure 4. Vesiculopapule with surrounding erythema on leg A complete blood count demonstrates a hemoglobin of 13.2 g/dL (132 g/L), hematocrit of 38.6% (0.386), platelet count of 449×10 …