Case 14-2012

Abstract

Pr e sen tat ion of C a seDr. Sarah Gee (Dermatology): A 43-year-old woman was admitted to the hospital because of fever and a generalized rash.The patient had a history of atopic dermatitis and had been in her usual health until approximately 1 week before admission, when a painful, pruritic rash developed on her chin, neck, and chest; it gradually spread to involve her entire body, sparing the palms, soles, and genitalia. Four days before admission, she went to the emergency department at another hospital. She reported that the rash was similar to but more severe than her usual atopic dermatitis, which was not painful. Prednisone and hydroxyzine were administered, and she was discharged home. The next day, the rash persisted, chills developed, and the temperature reportedly rose to 39.4°C. The patient returned to the other hospital. On examination, the temperature was 38.6°C, and the blood pressure, pulse, and oxygen saturation were normal. A diffuse, erythematous rash with vesicles, pustules, and excoriations involved the forehead, nose, lips, chin, periorbital areas, chest, back, arms, and legs and spared the palms, soles, and part of the cheeks. The complete blood count was reportedly normal.The patient was admitted to the other hospital, and clindamycin, hydromorphone, hydroxyzine, acetaminophen, and intravenous fluids were administered; white petrolatum ointment was applied to dry and cracking areas. The next day, a dermatologic consultation was obtained, and a skin biopsy and culture were performed. A chest radiograph was normal. During the second night, the temperature rose to 39.6°C, and sloughing of the skin occurred with pressure. Gram's staining of the skin-biopsy specimen reportedly showed no neutrophils or organisms; culture of the skin revealed a heavy growth of Staphylococcus aureus. Infectious disease consultation was obtained; the administration of clindamycin was stopped, and vancomycin and acyclovir were begun. The blood pressure ranged from 110 to 130 mm Hg systolic and from 50 to 69 mm Hg diastolic, and the oxygen saturation was 95 to 100% while the patient was breathing ambient air. Blood cultures were sterile. Other laboratory-test and culture results were pending. The patient was transferred to this hospital. Medications on transfer included vancomycin, acyclovir, hydromorphone, hydroxyzine, acetaminophen, and fluoxetine, with albuterol as needed.