Jump to content

Vesicular rash anyone? New case time...

Recommended Posts


42 yo female presents to local UC with a 1-day hx of itchy rash starting on her hands and spreading proximially, denies any other symptoms, no fevers or systemic complaints. Has a cat with fleas that sleeps in her bed. Lives with several roommates.

PMH: depression, HTN

SH: 1ppd smoker, occasional ETOH use, denies drug use, works in meat dept at grocery store


Exam: HR: 103 T: 36.9 RR 16 B/P 147/86

GA: Alert, NAD

Skin: Warm, dry, pink, rash: Bilateral upper extremities and inner thighs, excoriated, scabbed, consistent w/ scabies


Pulm: unlabored

Muskl: Normal ROM, normal strength

Neuro: A&Ox4


Diagnosis: Scabies, rash intensely puritic, does not appear inflamed, no other symptoms

Rx: Elimite cream


Represents on 5/21

Rash worsening, now generalized, itching and oozing, had chickenpox as a child. Elimite did not help. Denies fever cough. ROS negative except for joint pain.



HR: 114 B/P: 124/86 RR: 16 T: 36.9

GA: Alert, NAD

Skin: Warm, dry pink, Rash: Generalized, not oral, not on palms or soles, vesicular, circular raised, some oozing, some crusting, discrete margins, consistent with a viral infection.

HEENT: normal

Neck: supple

Resp: Unlabored


Muskl: Normal ROM, normal strength

Neuro: No focal deficits, normal sensory, normal motor


Diagnosis: Adult Varicella

Rx: Vicodin



Represents 5/22

Rash is worse, itching, swelling and oozing, has new symptom of myalgia and R-eye blurriness.

V/S: HR: 97 B/P: 134/80, T-37.4 RR: 18

Exam notable for no pharyngeal exudates, R-cojunctival inflammation, no meningial signs and no neuro deficits

Pt sent home, to follow-up with PCP


Represents 5/22:

Now with unrelenting pain, rash continues to grow in size, index finger turning dark purple, now reporting fever and weakness, no chills. Continue sto have weakness and myalgias.

Exam notable for pustular rash with vesicles, symmetric and raised with descrete margins. No other findings on exam.

This time labs were drawn:

VBG: 7.40/37/79/22

Procalcitonin: 11.9


Glu: 132 BUN:8 Cr: 0.5 Na: 136 K: 4.1 Cl: 107 CO2: 27 Ca: 8.1 Alb: 3.2

Bili: 0.3 Alk phos: 86 AST: 35 ALT: 23

CK 42

Troponin: <0.05

CBC: WBC: 8.6 RBC: 4.68 Hg: 14.5 HCT: 41.8 MCV: 89 RDW: 14.5 Plate 184

Neut% 87.7 Lymph: 5.3% ANC: 7.6 ALC 0.5 Segs 79% Bands 9% Lymph

UA: trace LE, urine micro 27 WBCs, 1 RBCs, moderate bacteria, refluxed to culture

UDS: positive oxycodone, pos amphetamines, pos MAMP

Vaginal swab: Clue cells, GC/Chalmydia negative


Pt admitted to OSH, started on Vancomycin and Rocephin, seen by ID consult who noted no new meds, has a cat at home as well as young children. Pt uses methamphetamines, denies IVDU. Handles meat at work, no one else sick. Has hx of childhood chickenpox.

Exam notable for multiple different morphologies of lesions, predominantly small, follicular, excoriated lesions over face, chest, back, abdomen and legs, hands and wrists with large areas of cracking and weeping bullae, hands with hemorrhagic bullae. No oral ulcers, no lesions on tongue. External genitalia spared.


Pt transferred to my service at tertiary academic center for further evaluation, I pick her up in the morning.

Here's what her skin looks like. What's your d/dx?

Link to comment
Share on other sites

Wow that is a pretty significant rash.


I'm by no means a rash expert nor do I have a clue what this is but just to get the ball rollin' How about A/I workup like CRP, HLA-B27, C4 Complement etc. Dont know how much utility or if these specific tests are appropriate but Immunology/Rheumatology/Dermatology consult might light the way.


My thoughts: Viral exanthem vs autoimmune process vs neurological etiology. Other than that you got me!


VictoriaO you come up with the toughest cases! LOL.


Lets see what our collective brain power here can come up with.


a culture of the vesicular fluid may also help...



Link to comment
Share on other sites

When you say the rash started on her hands, was it the dorsal aspects (always sparing palms)?


rash continues to grow in size, index finger turning dark purple

Is this due to a hemorrhagic bullae or is the digit ischemic? Are her fingers warm and have good cap refill?


Vaginal swab: Clue cells, GC/Chalmydia negative

This seems weird. Do you know why a wet mount was done? Is she having vaginal symptoms?


Procalcitonin: 11.9

It looks like this was done at the OSH. Just out of curiosity, is anyone else using pro-calcitonin? I've been following the articles supporting its use for differeniating bacterial vs. viral respiratory tract infections but doesn't seem like there's been enough consensus to use it in practice yet.


Quite a dramatic rash. What's her physical exam like now- does she still have right ocular symptoms (that would concern me)? Any eye pain? Visual acuitiy? What are her joints like? Any murmur?


Leaning towards ID over rheum but close call. Probably the most helpful consult would be dermatology.


Her legs due look scabies'ish- with the severity of symptoms, could be Norweigan Scabies with superinfection. Skin scraping would be helpful

Could be disseminated VZV. Would check her HIV status in addition

She has a cat- there's cat scratch fever but this is usually localized and not dissmeniated. Has she been bitten or scratched?

How is she using the meth? Is she injecting? Do you have blood cultures?

Her LFTs are normal. Hep C/cryoglobulinemia unlikely (plus have never seen bullae from this). What are her coags?


Looks a bit like bullous pemphigoid.

I'd also be thinking about ANCAs for vasculitis.

Link to comment
Share on other sites

my first thought was Reiters(sp) Syndrome....


Off topic, but did you know that Reiter's Syndrome is now simply known as reactive arthritis? Dr. Reiter turned out to have been an active Nazi Party member who worked at Buchenwald; they stripped him of his eponym a couple of years ago. This came up at work a few months ago during a discussion about Dubin's EKG book and Dr. Dubin's criminal record.

Link to comment
Share on other sites

Hmm, I'm bummed it won't let me upload more pics...had some good ones of the hemorrhagic bullae on her hands.


So our d/dx on admission was disseminated HSV or VZV with possible staph/strep superinfection, possible HIV predisposing to this, lower on the d/dx was Coxsackie, disseminated GC, consider Steven's-Johnson's syndrome, possible pustular psoriasis, other auto-immune reaction?


We got a Derm and ID consult, pumped her full of fluids (she looked dry as a bone, SIRSy and was leaking vesicular fluid all over the bed) and started IV Vanco and Acyclovir. We swabbed her vesicles for viral culture and also got an optho consult as she was complaining of blurry vision in her R-eye. Optho exam was negative for herpetic lesions or other findings.

Pt is unfortunately a very reticent historian (one of those responds "no" to everything, though she adamently denies IVDU and is annoyed everyone is making a "big deal" about her meth habits) and a "bit of a punk" as the night attending described her. She's been up smoking in the bathrooms and cursing at the nurses, but won't open her eyes or participate well in the exam. I'm not sure why the OSH did a vaginal exam, maybe to swab to rule-out disseminated GC? Anyways pt does endorse some joint pain, no other symptoms, no recent viral illness, no recent travel, etc. Denies any PMH or any FH of auto-immune conditions.


Exam is notable really for minimal physical exam findings other than the obvious, extremities are warm with good cap refill (not clamped down), no oral or genital lesions, no murmur, no lung findings, no joint effusions (other than her hands where the hemorrhagic bullae are). Vitals have been a bit SIRS-y, pt tachycardic to low 110's, B/Ps 90's-100's/60's, Temp 37-39, RR and O2 stats normal, tachycardia improving with fluids. EKG unremarkable.


Chemistries are unremarkable other than normal LFTs, an albumin of 2.2 and a mildly elevated AG to 13, CBC is notable for mild leukocytosis to 13.3, 19% bands, 3% lymphocytes, ANC of 9.6, #bands of 2.5, # of lymphocytes 0.4, INR 1.14

UA had some mild hematuria, but no other findings.

HIV, VZV, HSV, RPR, Hep C all cooking

Blood cultures so far are negative


CHEST 2 VIEWS, 05/24/12 06:46:00 COMPARISON: Quality Healthcare 05/22/12 HISTORY: Skin rash, tachycardia. FINDINGS: The lungs demonstrate patchy areas of lingular consolidation which are new, which is suspect for an early bacterial pneumonia. There is no pneumothorax or pleural effusion. The cardiomediastinal silhouette is within normal limits. The included abdomen, soft tissues, and osseous structures are unremarkable. IMPRESSION: Findings suspect for early lingula bacterial pneumonia.

Urine legionella, strep pneumo are negative.



Any other thoughts or comments before I post what the biopsy showed?

Link to comment
Share on other sites

I went to a ID dinner on varicella zoster , and it never crosses the midline.

Varicella can cross midline if it is disseminated, which is typically in immunocompromised hostS (HIV, onc pts etc). These patients are sick- not the regular zoster you see in the office. I have only seen it once in the hospital and not sure if the patient survived.

Link to comment
Share on other sites

I was going to say erythema multiforme vs. Stevens Johnson vs. toxic epidermal necrolysis. Could also be bullous pemphigoid or pemphigus vulgaris. Hard to tell from the pictures, but you mentioned she had pustules - could also be pustular psoriasis. She looks toxic. My question is why wasn't she started on Valtrex after the VZV diagnosis?

Link to comment
Share on other sites

could it be she has scabies resistant to elimite plus developed some secondary infection due to handling raw meat and open sores? One of the pictures looks like it could be stevens johnson syndrome, in which case I hope she was pumped with a bunch of steroids.

Link to comment
Share on other sites

Sorry for the delay in posting more to the case, our resident's graduation was this weekend so our hospital staff has been on skeleton crew. Luckily not too many admissions..


Great job adding to the d/dx guys! Disseminated moluscum is a great one to add in an HIV pt (we have another vesicular rash pt with HIV with disseminated varicella right now, these things come in waves). Erythema multiformae is great, SJS was on our list, though Nicholsky's sign was negative.


Essentially all infectious serologies were negative

HSV-viral culture neg






And the biopsy shows......................(drumroll).........................














Sweet's syndrome!



Not something any of us were really expecting, here's a great PDF review



So, to keep the case going as to the next issue we were boggling with, what triggered the Sweet's syndrome?

Anyone thing we should do further work-up before starting IV steroids?

Link to comment
Share on other sites


This topic is now archived and is closed to further replies.

  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More