Visual Diagnosis: Rash, Eye Pain, Lesions in an Adolescent

Abstract

1. Sarah Powers, MD* 2. Gina Carter-Beard, MD† 1. *Department of Pediatrics, University of New Mexico School of Medicine, Santa Fe, NM. 2. †Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Ore. A 17-year-old boy presents to his primary care practitioner with a 3-day history of rash, bilateral eye irritation, and sores in his mouth and on his genitals. He had been seen in the emergency department approximately 1 week ago for fever and a sore throat. A rapid streptococcal antigen test was positive at that time, and he was started on oral azithromycin therapy. Four days later, he developed facial swelling, eye redness, and “hives,” appearing initially on his hands, then spreading to his legs and feet. Although his sore throat resolved, new and different oral lesions appeared, and his lips became chapped and painful, prompting him to go to an urgent care clinic, where his azithromycin therapy was discontinued and he was started on oral prednisone and diphenhydramine. However, his skin lesions and eye pain continued to worsen, and sores appeared on his genitals. When he developed dysuria, he presented to his primary care physician for additional evaluation. The patient reports a history of allergy to penicillin, manifesting as hives in the past. Except for this past week, he takes no medications. There is no family history of skin disease. He is a sophomore in high school and smokes a half pack of cigarettes daily. He acknowledges occasional binge drinking and daily marijuana use but denies the use of other illicit drugs. He has been sexually active since the age of 16 years and has had many female partners, including some intercourse without protection, but denies any history of sexually transmitted infection. Physical examination reveals an alert, thin, but well-nourished adolescent male. His temperature is 37.0°C, respiratory rate is 18 breaths/min, …