Unusual Presentation with a Skin Rash

1Staten Island University Hospital, Staten Island, NY
2Staten Island University Hospital, Staten Island, NY
3Staten Island University Hospital, Staten Island, NY
4Staten Island University Hospital, Staten Island, NY
5Staten Island University Hospital, Staten Island, NY

Meeting: Hospital Medicine 2010, April 8-11, Washington, D.C.

Abstract number: 241

Case Presentation:

A 27‐year‐old woman with an unremarkable past medical history consulted her doctor because of a sore throat and difficulty swallowing consistent with a viral illness. Symptoms improved over the next 2 days until she developed malaise, myalgia, and arthralgia, mainly in the knees and ankles. Later that day, the patient noticed a rash over her entire body, which is reddish/purple, nontender, and nonpruritic. She denied weight loss, chest pain, fever, headache, and neck stiffness. She had no known allergies, history of bleeding disorder, recent dental interventions, recent travel, new sexual encounters, vaginal discharge, oral or genital ulcers, or evidence of urethritis. Physical exam showed a low‐grade lever and tachycardia with nonblanching petechial and purpuric red to violet lesions on all extremities, the chest and the palate. The patient was in no acute distress. No lymphadenopalhy or organomegaly were palpated, and the neck was supple. WBC was 13,000/μL with 89% granulocytes. PT/PTT, platelets and renal function were normal. ACXR and transthoracic echocardiogram were normal. The patient was started on ceftriaxone and vancomycin. She also received 60 mg of methylprednisolone IV and 1 dose of Tamiflu. CSF analysis was normal with negative Gram stain and nonreactive latex particle agglutinat for Neisseria meningitidis, Hemophilus influenza, Streptococcus B, and Streptococcus pneumonia. The viral workup for hepatitis A, B, and C, mmr, EBV, and CMV was negative. Lyme serology, RPR, and Rickettsial antibodies were negative. CH50 was 36 U/mL (31‐66 U/mL). The repeat CBC on hospital day 3 showed a WBC of 20,400/mm3, which decreased to 7.7 on day 5. The patient's condition did not progress to septic shock or purpura fulminans. She was relatively well throughout Ihe course of her illness, and she was discharged home on day 5 after near‐complete resolution of the rash. The differential diagnosis included mainly a viral illness versus a vasculitis, until the blood culture grew Neisseria meningitidis group B.

Discussion:

It is important to consider meningococcal infection in patients who have fever along with a skin rash even when there are no signs of meningitis or severe sepsis, knowing that the prompt recognition of the signs and symptoms and aggressive treatment remain the mainstay of survival. Droplet precautions should be initiated as soon as the disease is suspected. Petechiae are important indicators of the potential for bleeding complications secondary to disseminated intravascular coagulopathy, which may occur rapidly. Lower levels of bacteremia and/or less virulent strains may account for The absence of complications.

Conclusions:

Decrease in mortality has been reached, at least in Ihe UK, by better recognition of meningococcemia. The purpose of reporting this case is to increase general awareness of this condition.

Author Disclosure:

J. Daoud, none; A. Kushawaha, none; J. Rached, none; R. Nasr, none; N. Mobarakai, none.

To cite this abstract:

Daoud J, Kushawaha A, Rached J, Nasr R, Mobarakai N. Unusual Presentation with a Skin Rash. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 241. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/unusual-presentation-with-a-skin-rash/. Accessed October 17, 2019.

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