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Clinical Images

Rapidly Progressing Skin Rash

Saraschandra Vallabhajosyula, MBBS; George Raymond Wong, BA; Paul Gallup Millner, MD; Ann Lucretia Polich, MD MPH

January 29, 2016

A 57-year-old African-American man presented to our tertiary-care academic medical center with a worsening rash of two days duration with associated low-grade fever, scro-tal wounds with serous exudate, and increasing pruritis. The rash originated in the groin area and was associated with intense itching. Subsequently, he developed facial pain and pruritis with multiple lesions involving most of his head and neck. He reported additional developing lesions involving the upper and lower extremities, abdomen and gluteal areas. He denied any chills, dyspnea, weakness or mental status changes. His known atopic dermatitis (AD) had been managed conservatively in the past with hydroxyzine, menthol and occasional topical steroids, with intermittent episodes of secondary bacterial cellulitis and tinea cruris.. Due to the chronicity of his AD, he was started on methotrexate two days prior to this presentation.

Physical examination revealed a skin rash as documented in Figure 1. Vital signs demonstrated tachycardia with cardiorespiratory, abdominal, neurological and musculo-skeletal examinations otherwise unremarkable. Laboratory parameters revealed elevated inflammatory markers (erythrocyte sedimentation rate 21 mm/hr and C-reactive protein 4.1 mg/L) and positive blood cultures with Staphylococcus agalactiae. 

 

Figure1_Vallabhajosyula.jpeg

Figure2-Vallabhajosyula.jpeg




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References:

1. Wollenberg A, Wetzel S, Burgdorf WH, Haas J. Viral Infections in atopic dermatitis: pathogenic aspects and clinical management. J Allergy Clin Immunol. 2003 Oct;112(4):667-74. PMID: 14564342
2. Wollenburg A, Zoch C, Wetzel S, et al. Predisposing factors and clinical features of eczema herpeticum: a retrospective analysis of 100 cases. J Am Acad Dermatol. 2003 Aug;49(2):198-205. PMID: 12894065
3. Mackool BT, Goverman J, Nazarian RM. Case records of the Massachusetts Gen-eral Hospital. Case 14-2012. A 43-year-old woman with fever and a generalized rash. N Engl J Med. 2012 May 10;366(19):1825-34. PMID: 22571205
4. Nikkels AF, Pierard GE. Treatment of mucocutaneous presentations of herpes sim-plex virus infections. Am J Clin Dermatol. 2002;3(7):475-87. PMID: 12180895
5. Liaw FY, Huang CF, Hsueh JT, Chiang CP. Eczema herpeticum: a medical emer-gency. Can Fam Physician. 2012 Dec;58(12):1358-61. PMID: 23242894

Author Bios:

1. Saraschandra Vallabhajosyula, MBBS
Dr. Vallabhajosyula is a Critical Care Medicine Fellow at the Mayo Clinic College of Med-icine, Rochester MN. He completed his Internal Medicine residency at Creighton Univer-sity School of Medicine, Omaha NE where he took care of the patient in the clinical vi-gnette.

2. George Raymond Wong, BA
Mr. Wong is a MS-4 at Creighton University School of Medicine, Omaha NE. 

3. Paul Gallup Millner, MD
Dr. Millner is a second-year resident in Internal Medicine at Creighton University School of Medicine, Omaha NE. He was involved in caring for the patient during his intern year under the supervision of Dr. Vallabhajosyula and Dr. Polich

4. Ann Lucretia Polich, MD MPH
Dr. Polich is an Associate Professor of Medicine at Creighton University School of Medi-cine, Omaha NE. She is the Associate Chief of Staff for Patient Safety and Quality Im-provement and a Staff Hospitalist at the Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha NE.

 



 

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