A Wild and Wonderful Rash Clinical Pathological Case ACOEP 2014

1. A Wild and Wonderful RashClinical Pathological CaseACOEP 2014 Allison M. Remo, DO Emergency Medicine Resident, PGY-2 Ohio Valley Medical Center, Wheeling, WV

2. History • 60-year-old white male with CC of flu like symptoms • Onset: 1 week prior to presentation • Associated symptoms: • Increasing fatigue, HA, nausea starting on Monday. • Progressed to vomiting by Wednesday. • Developed a rash all over his body, starting on his stomach, and spreading to his extremities and neck. • Non-productive cough, appetite and fluid intake have been greatly decreased, and lower back pain. • Wife states he has been sleeping 90% of the time and, at times, will not make sense when he talks.

3. History • Past Medical History • CAD, HTN, type 2 DM, hyperlipidemia, history of MRSA skin infection • Past Surgical History • CABG ~10 years ago, I&D of MRSA lesion on back • Family History • Father: acute MI at age 52, Mother: cervical CA, Grandfather: prostate CA

4. History • Social History • Patient is married with 2 sons, retired truck driver this past year. • Former smoker, quit in 1986, denies drug use, occasional beer drinker about once a week. • Denies any recent travel in or out of the country, denies any recent camping or hiking.

5. History • No Known Drug Allergies • Medications • Metformin 1000mg PO BID • Metoprolol 100 PO mg Q day • ASA 81 mg PO Q day • Lisinopril/HCTZ 20/25 1 tab PO Q day • Lipitor 20 mg PO Q day • Vaccinations • Does not get the flu vaccination

6. Review of Systems • Positive: • Constitutional: Fatigue, anorexia, decreased oral intake, subjective fever, chills, increase in sleep • CNS: Headache • Pulmonary: Cough with non-productive sputum • Abdominal: Nausea, vomiting • Musculoskeletal: Lower back pain • Skin: Maculopapular rash • Patient denies: Chest pain, shortness of breath, epistaxis, blood in stool or in vomitus, diarrhea, constipation, change in weight, double or blurry vision, neck pain

7. Physical Exam • Vitals: • T: 99.3°F, Pulse: 94, RR: 18, BP: 96/48 mm hg, Pulse Ox: 99% • General Appearance: • Alert +orientated x 3, obese, NAD, speech is clear and unlabored, maculopapular blanching rash is noted over the body and extremities. • HEENT: • PERRLA, EOMI, AT/NE, conjunctiva clear, oropharynx clear, no petechial noted in hard palate, questionable petechia sublingually, no posterior pharynx exudate.

8. Physical Exam • Neck: • No masses, no tenderness to palpation or lymphadenopathy midline or paracervically, range of motion intact, trachea midline, no thyromegaly. • Pulmonary: • Diffuse bilateral wheeze, no crackles noted. • Cardiovascular: • Normal S1 and S2, no murmurs, regurgitations or gallops noted. No tenderness to chest wall palpation. • Abdomen: • Soft, nt/nd, positive bowel sounds all 4 quadrants.

9. Physical Exam • Extremities: • No edema, no deformities, 2 + pedal pulses bilaterally, no clubbing cyanosis. • Rectal: • No masses, heme negative. • Neurologic: • A+O x 3. No focal motor or sensory deficits. CN2-12 grossly intact. Muscle strength 5/5 upper and lower extremities b/l sensation equal and symmetric upper and lower extremities b/l.

10. Physical Exam • Skin: • No ulcers, maculopapular,blanching erythematous, discrete rash from the neck down, trunk, posterior back, upper and lower extremities. No rash noted on soles of feet or palms of hands.

11. Labs: CBC w/Differential • Platelet Count: 79 K/uL • Lymphocytes: 6.5% • Monocytes: 3.8% • Band Neutrophils: 12% • Basophils: 0.4% • Eosinophils: 0% • Smudge Cells: 1 • WBC: 8.4 K/uL • RBC: 4.39 M/uL • Hb: 12.7 g/dL • Hct: 36% • MCV: 82.1 fl • MCH: 29.1 pg • MCHC: 35.4 g/dL • RDW: 11.8

12. Labs: CMP • Ionized Calcium: 3.5 mg/dL • Total Bilirubin: 0.7 mg/dL • AST: 135 u/L • ALT: 78 u/L • Alkaline Phosphatase: 70 u/L • Albumin:3.6 g/dL • Total Protein: 7.9 g/dL • Calc Osmolality: 259 mosm/kg • Sodium: 121 mmol • Potassium: 3.5 mmol/L • Chloride: 82 mmol/L • CO2: 23 mmol/L • Anion Gap: 16 • BUN: 52 mg/dL • Creatinine: 2.56 mg/dL • GFR: 26 • Glucose: 127 mg/dL • Calcium: 8.6 mg/dL

13. Labs: Arterial Blood Gas • Modified Allen Test: Ok • Respiratory Index: 24 • Oxyhemoglobin: 94.6% • Methemoglobin: 1.2% • Carbon Monoxide: 1% • FiO2: 0.21 • Sample Site: Right Radial • pH: 7.52 • pCO2: 25 mm hg • pO2: 84.4 mm hg • Bicarbonate: 20.4 meq/L • Base Excess: -1.0 meq/L • O2 Saturation: 96.7% • ABG O2 Content: 16.7 vol% • Total Hemoglobin: 12.5 gm% • A/a PO2 Ratio: 31.81 mm hg

14. Lab: Urine Analysis • Urobiliogen: 0.2 eu/dL • RBC: 0-3 • WBC: 0-5 • Squamous Epithelium: 0-5 • Bacteria: Occasional • Mucus: Occasional • Coarse Granular Casts: 0-5 • Collection Type: Clean catch • Color: Yellow slightly hazy • pH: 5.5 • Specific Gravity: 1.015 • Protein: Trace • Glucose: Negative • Ketones: Negative • Blood: Small • Nitrite: Negative • Bilirubin: Negative

15. Lab: Cerebrospinal Fluid • Protein: 90.7 mg/dL • Glucose: 69 mg/dL • Cell Count: • Gross Appearance: Water clear • Supernatant Appearance: Water clear • Clarity: Slightly hazy • RBC Count: 850 cells/uL • WBC Count: 300 cells/uL • Differential: • Granulocytes: 46%,Lymphocytes: 38%, Monocytes: 16%

16. Lab: Cerebrospinal Fluid • Directigen: • Strep. Pneumoniae: Neg • Group B Streptococcus: Neg • N. Meningitis group C,W135: Neg • N. Meningitis Type A,Y: Neg • N. Meningitis Group B/E. Coli K 1: Neg • H. Influenzae Type B: Neg

17. Radiology • Chest X Ray

18. Radiology • CT without Contrast of the Abdomen and Pelvis

19. Radiology • CT without Contrast of the Brain

20. Emergency Department Course • Patient was given a 1 L NS fluid bolus due to his hypotension and his pressure did slowly improve with repeated boluses. • Blood cultures were obtained and other special testing was obtained which was sent out to be resulted.

21. Disposition • Patient was then transferred to the Ohio Valley Medical Center intensive care unit for further diagnostic work-up and treatment.

22. What’s your diagnosis?