Visual Diagnosis: An Adolescent Who Has Fever, Joint Pain, a Rash, and "Blacking Out" Episodes

Abstract

1. Katie Burco, MD* 2. Joseph A. Zenel, MD† 1. *Doernbecher Children's Hospital, Oregon Health Sciences University, Portland, Oregon 2. †Associate Editor A 15-year-old female presents to her primary care physician with a 2-month history of intermittent fevers, rash, “blacking out,” arthralgias, headaches, and weight loss. The rash first appeared on the axillae and upper back, later spreading to her chest, abdomen, buttocks, face, and hands. Soon joint pain developed in her knees, shoulders, elbows, and spine, with the pain more pronounced in the morning. A review of systems reveals transient bilateral ankle swelling, occasional nausea and vomiting, night sweats, abdominal pain with loose stools, fatigue, and intermittent shortness of breath. Her last menses occurred 2 weeks ago while on depot-medroxyprogesterone. She denies gross hematuria. The rest of the review of systems is normal. The patient's past medical history is remarkable for three separate “blacking out” episodes occurring 2 months ago before her current complaints appeared. At that time, results of head computed tomography scan and electroencephalography (EEG) were normal. Current medications include medroxyprogesterone, ibuprofen, and oxycodone (for arthralgias). She smokes a half pack of cigarettes daily, drinks moderately, and is sexually active. Her father has had a cerebrovascular accident, and her cousin has schizophrenia. The physical examination reveals an alert, well-developed, well-nourished adolescent female. Her temperature is 98.6°F (37°C), respiratory rate is 24 breaths/min, heart rate is 91 beats/min, and blood pressure is 117/45 mm Hg. Her weight is 56 kg (70th percentile for age). The skin examination reveals multiple tender, red, scaly, irregular annular plaques with raised borders on her face, neck (Fig. 1), back, chest, abdomen (Fig. 2), buttocks, and the flexural surfaces of her arms (Fig. 3) and knees. Her head, eyes, ears, nose, and throat examinations show bilateral boggy conjunctivae, mild bilateral papilledema, and bilateral rubbery posterior and anterior cervical lymph nodes that are approximately 2 cm in diameter. Auscultation of her chest reveals clear and equal …