SAEM Clinical Images Series: Not Your Average Eczema

eczema

A 3-year-old male with a history of severe atopic dermatitis presented for facial rash and hand pain. Mom had been applying Aquaphor and Vaseline several times a day. On the day of presentation, he woke up with a new rash over his face and hands which prompted the ED visit. He is up to date on childhood immunizations and is not prescribed any oral medications.

Additional Images

Physical Exam

Vitals: BP 103/61; HR 156; Temp 102.9°F; RR 30; SpO2 99%.

General: He appears in no acute distress, acting appropriately for age. Interacts and follows commands. Scratching himself all over.

Skin: Diffuse, itchy, dry skin throughout and findings noted in the attached images most notably erythematous pustules on the dorsal hands and peri-oral lesions in addition to punched-out ulcerations on the philtrum. Lesions are tender to palpation and spare mucous membranes and palms/soles. Nikolsky sign negative.

Laboratory Data

WBC: 12.96

Skin scraping: +VZV

Case Question: What is the likely diagnosis?

This patient has Eczema herpeticum as demonstrated by multiple grouped pustules on an erythematous base.

Given the extensive facial involvement, what service other than dermatology should be consulted?

Ophthalmology should be consulted to rule out ocular involvement most notably herpes zoster ophthalmicus.

Case Discussion

Take-Home Points

Eczema herpeticum is typically caused by superinfection of Herpes Simplex Virus due to a diminished skin barrier from atopic dermatitis. It is commonly misdiagnosed as impetigo. Grouped vesicles/pustules on an erythematous base and tenderness to palpation should prompt the physician to suspect herpetic skin infection.
Eczema herpeticum may be potentially life-threatening if it has spread to multi-system involvement such as HSV keratitis or encephalitis.
Treatment includes acyclovir in addition to gram positive coverage such as TMP/SMX or cephalexin.

References

American Academy of Pediatrics: Herpes simplex. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:432–445.
Studdiford JS, Valko GP, Belin LJ, Stonehouse AR. Eczema herpeticum: making the diagnosis in the emergency department. J Emerg Med. 2011 Feb;40(2):167-9. doi: 10.1016/j.jemermed.2007.11.049. Epub 2008 Jun 27. PMID: 18584994.

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Edward Guo, MD|2024-12-02T22:01:54-08:00Dec 20, 2024|Dermatology, SAEM Clinical Images|

SAEM Clinical Images Series: An On-Target Diagnosis

erythema

A 25-year-old female with no pertinent past medical history presented to an emergency department in Massachusetts with four days of generalized malaise, myalgias, congestion, low-grade fever, and a rash behind her left knee. The patient denied cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, and diarrhea. She lives with three roommates, none of whom were sick, and she denied any other known sick contacts. She also denied any occupational exposures or recent travel, although did endorse some recent hiking in the area.

Physical Exam

Vitals: BP 128/84; HR 88; Temp 98°F; RR 18; SpO2 (on RA) 100%

General: Well appearing

HEENT: No conjunctival injection

Cardiovascular: S1, S2; no murmurs, rubs, or gallops

Skin: Erythematous patch with central clearing in left popliteal fossa

Laboratory Data

WBC: 5.1

Hgb: 12.6

Platelets: 223

Sodium: 139

Creatinine: 0.8

ALT/AST: 22/22

COVID/Influenza/RSV: negative

Case Question: What is the name of the rash shown and what underlying disease does it signify?

This clinical image depicts erythema migrans (EM), the classic rash seen in 70- 80% of early localized Lyme disease infections. Lyme disease is a bacterial infection caused by the spirochete Borrelia burgdorferi, transmitted through bites from Ixodes scapularis (Blacklegged Tick). Lyme disease is endemic to the northeastern part of the United States but is also commonly reported in the upper Midwest region of the country. There are three stages of Lyme disease: early localized infection, early disseminated infection, and late disseminated infection. Early localized infection starts 3-30 days after a tick bite. This stage is characterized by the EM rash as well as fatigue, low-grade fevers, malaise, myalgias, and lymphadenopathy. EM develops at the site of the tick bite, although only 25% of patients with the characteristic rash recall being bitten by a tick. Over the next several days, the rash will expand and may develop a central clearing. Thus, the rash is often described as appearing like a “bull’s eye” or a “target.” Serological testing may be negative in early Lyme disease thus diagnosis at this stage is usually clinical.

Case Question: What treatment is indicated for this patient?

Treatment for early localized infection is typically Doxycycline 100mg PO BID x 10-14 days. Cefuroxime 500mg PO BID x 14 days is another option. Amoxicillin 500mg PO TID x 14 days is the preferred antimicrobial in patients who are pregnant and/or breast-feeding. As when treating infections caused by other spirochetes such as Treponema pallidum, a Jarisch- Herxheimer reaction may occur. Left untreated, disseminated disease will develop in 60% of patients. Most symptoms will occur within days to months, although late disseminated disease may take months to years to present. A wide range of clinical presentations are possible with early disseminated disease including diffuse annular skin lesions, meningoencephalitis, cranial nerve palsies (most commonly Bell’s Palsy), peripheral neuropathies, and AV nodal blocks. Late disseminated infection can present with transient, migratory oligoarticular arthritis and non-focal nervous system symptoms such as mild encephalopathy and fatigue. Serological studies in disseminated disease are highly sensitive and the CDC recommends two-step testing such as an enzyme immunoassay or immunofluorescent antibody assay followed by a Western blot if the initial testing is positive or equivocal. Treatment of disseminated Lyme depends on the systems involved. Given the ambiguity of early serologic testing and the potential for development of disseminated disease, erythema migrans is a clinical “can’t miss” dermatologic diagnosis in the emergency department.

Case Discussion

Take-Home Points

Lyme disease is caused by bites from the Blacklegged Tick and is endemic to the northeastern United States.
Early localized Lyme infection often presents with the erythema migrans rash, a large targetoid or bull’s eye area of erythema with central clearing at the site of the tick bite.
The diagnosis of early Lyme is usually clinical and the three first-line antibiotics are Doxycycline, Cefuroxime, or Amoxicillin.

References

Kowalski TJ, Tata S, Berth W, Mathiason MA, Agger WA. Antibiotic treatment duration and long-term outcomes of patients with early lyme disease from a lyme disease- hyperendemic area. Clin Infect Dis. 2010 Feb 15;50(4):512-20. doi: 10.1086/649920. PMID: 20070237.
Lyme Disease. Centers for Disease Control and Prevention. 2022, Jan 19. https:// www.cdc.gov/lyme/
Steere AC. Lyme disease. N Engl J Med. 2001;345(2):115-125. doi:10.1056/NEJM200107123450207 4. Torbahn G, Hofmann H, Rücker G, Bischoff K, Freitag MH, Dersch R, Fingerle V, Motschall E, Meerpohl JJ, Schmucker C. Efficacy and Safety of Antibiotic Therapy in Early Cutaneous Lyme Borreliosis: A Network Meta-analysis. JAMA Dermatol. 2018 Nov 1;154(11):1292-1303. doi: 10.1001/jamadermatol.2018.3186. PMID: 30285069; PMCID: PMC6248135.

By Daniel Xia, MD|2024-12-02T21:38:35-08:00Dec 9, 2024|Dermatology, Infectious Disease, SAEM Clinical Images|

SAEM Clinical Images Series: This Rash Came Out of No Where

crusting

A 26-year-old male with a past medical history of eczema presented to the Emergency Department with a rash for two days. The patient stated he first noticed a rash on his right arm that rapidly spread to his face, chest, and left arm. He reported having similar rashes before but never to this extent. The patient stated he was given Bactrim and amoxicillin about one month ago for another rash, though he was unsure of the diagnosis. He denied any known allergies or exposures to new foods or hygiene products. He had no chest pain, SOB, nausea, or diarrhea. He lives in a correctional facility and does not know of anyone with any rashes.

Additional Images

Physical Exam

Vitals: Temp 102.7°F; BP 134/81; HR 137; RR 17; O2 100% on room air

Cardiac: Tachycardic, no murmurs

Lungs: CTABL

Skin: Pustular vesicles with scattered areas of confluency on face, upper extremities and torso. Yellow crusting on face, no mucosal involvement.

Laboratory Data

WBC: 17

Platelets: 261

Blood cultures: One of two positive

CMP and UA WNL

Case Question: What is the diagnosis?

Non-bullous Impetigo

Impetigo is a rash that effects the epidermis. There are two main types, bullous and non-bullous. S. Aureus and S. Pyogenes are the most common causes of non-bullous impetigo with S. Aureus accounting for up to 80% of cases. Impetigo is highly contagious and patients often self-inoculate other areas of their skin after the initial lesion develops. As papules develop, they fill with pus and once ruptured a classically characterized honey-colored crust is left on the skin. It is more common in immunocompromised patients, diabetics, patients with poor hygiene, and those patients who spend time in crowded dwellings such as daycare or prison. Systemic antibiotics are recommended in all cases of bullous impetigo and in non-bullous impetigo if there are more than five lesions, signs of deeper tissue involvement, or systemic symptoms as was the case with this patient. Beta-lactamase-resistant antibiotics such as Keflex or Augmentin are often the first line and if the patient resides in an area with a high prevalence of MRSA, doxycycline or clindamycin are recommended. Once diagnosed, it is important to wash any clothing, bedding, or infected surfaces to prevent further household or community spread. In the case of this patient, he developed systemic symptoms ultimately becoming septic, and required admission with IV antibiotics. He made a full recovery.

Case Discussion

Take-Home Points

Suspect in patients who are immunocompromised or have contact with crowded dwellings such as daycare or jail.
The classic skin finding is a honey-colored crust.
Patients with systemic symptoms or more than five lesions need systemic antibiotics.

References

Nardi NM, Schaefer TJ. Impetigo. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK430974/
Group A Strep Infection. (n.d.). Group a Strep Infection. https://www.cdc.gov/group-a-strep/?CDC_AAref_Val=https://www.cdc.gov/groupastrep/diseases-%2520hcp/impetigo.html

By Melissa Smith, MD|2024-12-02T21:22:36-08:00Dec 3, 2024|Dermatology, Infectious Disease, SAEM Clinical Images|

SAEM Clinical Images Series: A Rash with Cranial Nerve Deficits

rash

A 48-year-old male with no significant past medical history presented to the Emergency Department with a left-sided facial rash and associated burning left eye pain that started four days prior. He was seen at an ophthalmology clinic when his symptoms started and given oral valacyclovir which he took for three days without improvement. He also endorsed left-sided facial weakness and diplopia for the last eight days. He denied fevers, chills, nausea, vomiting, ear pain, tinnitus, hearing changes, blurry vision, photophobia, history of malignancy or HIV, history of stroke. He reported remote use of tobacco nine months prior, cocaine use that stopped three weeks prior, and alcohol use only on weekends.

Additional Images

Physical Exam

Vitals: Temp 36.8°C; BP 148/85; HR 80; RR 18; O2 Sat 96% on room air

General: Alert, no acute distress.

Skin: Healed vesicular rash along V2 distribution of trigeminal nerve.

Head: Normocephalic, atraumatic.

Eye: Visual acuity – right 20/40, left 20/70 without correction (at baseline per patient). Left eye viewed with fluorescein showing dendritic lesions. EOM: right intact, impaired abduction of left eye. Unable to close the left lid. Pupils: R pupil 3mm, briskly reactive to light, L pupil 3mm not briskly reactive

Ears: Without vesicular lesions bilaterally

Cardiovascular: Normal peripheral perfusion.

Respiratory: Respirations are non-labored.

Neurological: Alert and oriented to person, place, time, and situation. Cranial nerves: CN II grossly intact, CN III: left pupil reactive to light but sluggish, CN V: facial sensation to light touch intact, CN VI: impaired abduction of left eye, CN VII: left facial droop with left forehead involved, CN VIII – XII intact. 5/5 motor strength to bilateral upper and lower extremities, no sensory deficits, has a steady gait.

Laboratory Data

CBC, BMP, and ESR all within normal limits.

Case Question: What is your differential based on the images and physical exam findings?

The patient has a left-sided painful vesicular rash in the V2 distribution of the trigeminal nerve and dendrites on fluorescein-stained exam of the left eye, concerning for herpes zoster ophthalmicus. Hutchinson sign (involvement of the tip or side of the nose, as seen in the images) indicates involvement of the nasociliary branch of the trigeminal nerve, and patients with this finding have an increased risk of ocular involvement [1]. Although this patient did not have auditory canal involvement, Ramsay Hunt Syndrome is also important to consider. The image also shows impaired abduction of the left eye, concerning for a CN VI palsy, and the physical exam showed sluggish left pupil reactivity to light, concerning for a CN III palsy. Given the patient reported diplopia and had multiple cranial nerve deficits, cavernous sinus syndrome was also a differential diagnosis.

Case Question: What would your next steps in management be?

The recommended treatment for herpes zoster ophthalmicus is oral Valacyclovir, however, if there is any concern for disseminated zoster (3 or more dermatomes involved, CNS involvement, or other extradermal complications), patients should be treated with IV Acyclovir 10 mg/kg based on ideal body weight every 6 hours [1]. Since this patient underwent a trial of Valacyclovir without improvement and there was concern for possible CNS involvement with multiple cranial nerve deficits on exam, the patient was started on IV Acyclovir. Consultation with ophthalmology is also recommended for management of zoster ophthalmicus. The presence of diplopia, CN III and CN VI palsies was also concerning for possible cavernous sinus syndrome, which can be caused by a broad range of infectious, inflammatory, neoplastic, and vascular pathologies. It can have varying presentations based on the affected neurovascular structures however the constellation of symptoms includes diplopia, ophthalmoplegia, Horner syndrome, facial sensory loss, and CN III, VI, and VI deficits. If it is suspected, MRI with and without contrast is the preferred imaging modality to determine the location and extent of disease [2]. Neurology consultation is also helpful in co-management.

Case Discussion

Take-Home Points

In a patient with a facial vesicular rash, it is important to perform a full cranial nerve exam to evaluate for deficits that may indicate CNS involvement, inspect the anterior chamber to evaluate for zoster ophthalmicus, and examine the ears to evaluate for Ramsay Hunt Syndrome.
Start antivirals early if zoster ophthalmicus is suspected since this disease process can be vision-threatening.

References

Anderson Erik, Do-Nguyen Amy. Varicella-Zoster Virus (VZV). In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/ corependium/chapter/recV6PonFTQbz5R9c/Varicella-Zoster-Virus-VZV#h.q140vny9bkbo. Updated August 16, 2023. Accessed January 11, 2024.
Munawar K, Nayak G, Fatterpekar GM, et al. Cavernous sinus lesions. Clinical Imaging. 2020;68:71-89. doi:https://doi.org/10.1016/ j.clinimag.2020.06.029

By Veda Ravishankar, MD|2024-11-13T09:40:41-08:00Nov 18, 2024|Dermatology, Ophthalmology, SAEM Clinical Images|

SAEM Clinical Images Series: Red Rash on My Legs

milaria

A 23-year-old female with no known past medical history presented with a rash concentrated on her legs, with a few areas on her arms and chest. The rash began the day before presentation when she became overheated while wearing sweatpants in 104°F weather. The rash was mildly pruritic but not painful. She denied any prior reaction to her sweatpants that she has had for several months. She denied any new soap or cosmetic use, prior rash, allergy, or medication use. Her review of systems and past medical history were negative.

Additional Images

Physical Exam

Vitals: Normal

Skin: An erythematous papular rash is concentrated and symmetric on her lower extremities. There are a few sparse lesions on her arms, thorax, and abdomen with sparing of the palms, soles, and face. No pustules or vesicles are noted. There is no scale or crust. No other skin lesions are present. The rest of the examination is normal.

Laboratory Data

Non-contributory

Case Question: What is the diagnosis?

Miliaria, or prickly heat (heat rash).

Miliaria, also known as prickly heat or heat rash, is caused by blocked eccrine sweat glands and ducts. Exposure to heat with sweating causes eccrine sweat to pass into the dermis or epidermis causing a rash. It is common in warm and humid climates during the summer months. It can affect up to 30% of adults living in hot and humid conditions. It may present as vesicles, papules, or pustules depending on the depth of the eccrine gland obstruction. In adults the rash is most likely seen where clothes rub on the skin. Infants and children typically have lesions on the upper trunk, neck, and head. Miliaria is a clinical diagnosis. Treatment involves measures to reduce sweating and exposure to hot and humid conditions. Air conditioning and the reduced humidity of indoor environments are helpful. If significant inflammation is present with pruritis, some improvement can be seen with 0.1% triamcinolone topically, though ointment should be avoided and only cream or lotion applied.

Case Discussion

Take-Home Points

Miliaria, or prickly heat, is caused by sweating and blocked eccrine sweat glands.
Treatment involves retreating to cool, indoor environments.
Triamcinolone 0.1% cream or lotion may reduce pruritis.

References

Guerra KC, Toncar A, Krishnamurthy K. Miliaria. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30725861.

By Walter L Green, MD|2024-03-26T10:26:51-07:00Apr 1, 2024|Dermatology, SAEM Clinical Images|

SAEM Clinical Images Series: Neonatal Rash

An 18-day-old male presented for a rash on his face for two days. The patient was born via spontaneous vaginal delivery full term without complications to a mom who has a history of genital HSV but without active lesions at delivery and on acyclovir. The patient presented with a vesicular rash on his face including around his eyes. He had conjunctival discharge noted by mom. Otherwise, he was well-appearing, acting normally, and eating/voiding/stooling normally.

Additional Images

Physical Exam

General: Well appearing, acting appropriately for age

HEENT: Scalp normal. Anterior fontanelle soft and flat. Vesicular appearing rash with erythematous base in clusters noted around eyes, cheek, and chin. Fluorescein staining with corneal abrasion noted at 4 o’clock region on right eye, no dendritic pattern. Scant yellow discharge noted from left eye. TM normal bilaterally. Oropharynx clear.

Neuro: Normal tone, moving all extremities

Skin: Flaky skin, no rash noted elsewhere except as listed above (Photos taken after fluorescein)

Laboratory Data

CBC: Normal

LFTs: Normal

BMP: Unremarkable

CRP: Negative

Lab results for HSV were negative:

HSV 1 and 2 (chin): negative

HSV 1 and 2 (near eye): negative

HSV 1 and 2 (nose, mouth, rectum): negative

HSV 1 blood Igg: negative

HSV 2 blood Igg: positive (reflective of maternal antibody status)

Case Question: In an otherwise healthy child with no neurological findings, what are some benign common rashes?

What was once called “neonatal acne” now known as neonatal cephalic pustulosis is usually seen in the first three weeks of life. Usually, it appears as pustulo-papules on the face, around the eyes, on the cheeks, and chin. Some studies have suggested that neonatal cephalic pustulosis is caused by Malassezia species. As the rash is self-limiting, treatment is not necessary.

Case Discussion

Take-Home Points

When a vesicular rash is in a neonate < 1 month and all over the face, consider benign neonatal pustular lesions such as neonatal cephalic pustulosis.

References

Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD. Clinical and therapeutic approach to childhood acne: an update. Pediatr Dermatol. 2009 Jul-Aug;26(4):373-80. doi: 10.1111/j.1525-1470.2009.00932.x. PMID: 19689511.
Ghosh S. Neonatal pustular dermatosis: an overview. Indian J Dermatol. 2015 Mar-Apr;60(2):211. doi: 10.4103/0019-5154.152558. PMID: 25814724; PMCID: PMC4372928.

By Li Ding, MD|2024-04-01T09:12:19-07:00Feb 26, 2024|Dermatology, Pediatrics, SAEM Clinical Images|

SAEM Clinical Images Series: Back Lesion

skin lesion

An 18-year-old-female with no known past medical history presented with a lesion on her back that had been present and enlarging for five months. It was not painful unless she touched it, and then only mildly tender. She denied any known cause, wound, prior rash, or other lesions. Her review of systems and past medical history were negative.

Additional Images

Physical Exam

Vitals: Normal

Skin: An erythematous lenticular, or biconvex, lesion with distinct borders is noted at the left posterior thorax below the scapula. It is soft with some slight nodularity on palpation, and only mild tenderness noted. There is no fluctuance. No other skin lesions are present. The rest of the examination is normal.

Laboratory Data

Ultrasound reveals a 1.7 x 0.8 x 1.1 cm superficial soft tissue mass inferior to the scapula on the left thorax.

CT scan of the chest confirms no intrathoracic extension or other lesions.

Case Question: Is the next appropriate step antibiotics, antifungals, topical steroids, or biopsy?

Biopsy is the next appropriate step. The lesion does not appear to be infectious, either viral, bacterial, or fungal. Furthermore, it has no appearance of an inflammatory reaction that would benefit from topical steroids. The differential includes a cystic structure, neurofibroma, or malignancy. Because of the concern for malignancy, a biopsy was performed in the emergency department after the ultrasound and CT scan confirmed there was no extension into the thorax. The biopsy revealed a pilomatrixoma, or pilomatricoma. Pilomatrixoma is a superficial benign skin tumor that arises from hair follicle matrix cells. They commonly occur in the first two decades of life with a mean age of 17 years. The most common presentation is an asymptomatic, firm, slowly growing mobile nodule. However, only 16% are accurately diagnosed on clinical examination. This case reveals the wide variation in visual presentation and confirms the inability to diagnose the lesion at the bedside. Complete surgical excision is curative.

Case Discussion

Take-Home Points

Unknown skin lesions, with concern for malignancy, should be diagnosed by biopsy.
Pilomatrixoma is rarely diagnosed at the bedside.

References

Jones CD, Ho W, Robertson BF, Gunn E, Morley S. Pilomatrixoma: A Comprehensive Review of the Literature. Am J Dermatopathol. 2018 Sep;40(9):631-641. doi: 10.1097/DAD.0000000000001118. PMID: 30119102.

By Walter L Green, MD|2024-01-28T21:32:23-08:00Feb 2, 2024|Dermatology, SAEM Clinical Images|

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