Presenter: Peter Vitulli Jr. D.O. Third year resident, Chris Manlio D. O. first year resident
Dermatology Program: North Broward Hospital District
Program Director: Stanley E. Skopit D.O.
Submitted on: Nov 30, 2003
CHIEF COMPLAINT: A 17-year-old Hispanic female was admitted to the hospital with fever, malaise, and skin rash with suspected bacterimia.
Signs and symptoms: Patient complained initially of pruritis with subsequent burning pain of skin, which worsened with movement. Patient had concomitant fever up to 103.7, nausea, anorexia, and malaise.
Previous Treatment: Psoriasis in the past had been controlled with topical mid to high potency steroids as well as dovonex oint.
Other information: The patient was seen approximately 6 days prior to admission by her dermatologist for a worsening of her psoriasis. She was noted to have multiple erythematous macules confluent to patches in the flexor areas and concomitant silvery plaques on the extensor surfaces of her elbows and knees. At that time the patient was started on triamcinolone 0.1% cream BID and dovonex ointment BID to the affected areas. Over the course of 6 days her rash became wide spread over her entire body with formation of pustules and was admitted to the hospital by her pediatrician.
temp 103.1, Heart rate 104, Respiratory rate 18, Blood pressure 108/62
Gen: Awake, Alert, Oriented X 4, ill appearing female with guarding of movement secondary to pain.
Skin: Diffusely erythrodermic with multiple pustules confluent to lakes of pus on trunk, face, and extremities. Multiple areas of denuding skin were noted. A mild fecal odor was noted.
HEENT: Neck was supple, oral phary7nx was noted to have slight erythema and mild fissuring of the lips.
Remainder of exam was unremarkable.
Labs: abnormalities on Day 1 wbc 18.4, Hb 11.2, Hct 33.4 on Day 7 wbc 10.9 Hb 11.8 Hct 34.2 remainder of blood work including liver functions were normal.
Skin biopsy revealed parakeratosis, prominent Munro’s microabcesses, focal spongiform pustule formation, and superficial and deep polymorphous infiltrate, containing multiple polymorphonuclear leukocytes, psoriasiform acanthosis and papillary dermal telangectasia and edema.
1. Pustular Psoriasis
2. Steven’s Johnson’s Syndrome
4. Kawasaki’s Disease
5. Acne Fulminant