Age: 15.0
Sex: M
Vaccine: TD
Symptoms: Rash, Rash maculo-papular, Tenderness, Vomiting, White blood cell count increased
Clinical narrative: Dt booster 5/17/05, chest pain 5/18/05, red raised rash, sore throat 5/19/05, fever 5/20/05, vomiting 5/22-5/24, Increased WBC 191200. There are an additional 4 pages of report of consultation. 15 year old was in good health until 5/17/05 when he received a tetanus vaccine. Within one hour he developed some mild chest pain. While he went to school the following day, the original chest pain was worrisome and he went to his PCP office on 5/18 for evaluation. I do not believe that any clear diagnosis was made. By the following day 5/19, the pt developed some palmar tenderness and within several hours he recalls having bumps under the skin of his hands and some associated hand pain. During the course of the day, the exanthem spread to involve his forearms and then his chest and abdomen. He was seen in the emergency dept on 5/19 where he was found to have a temperature of 98.9, blood pressure of 117/70 and O2 sat 99% on room air. His palms are noted to be slightly erythematous and mildly tender to palpation and he had an erythematous papular rash involving the forearms and abdomen, this was felt to involve primarily the hair follicles and a ? of folliculitis was raised. A rapid strep test was negative. Benadryl and Pepcid were prescribed as the pt was complaining of some mild dyspepsia at the time. By 5/20, the pt began having fevers and loose stools three or more each day and described as watery. The exanthem became more confluent. On that day, he saw his PCP office again and was thought to have a possible viral process. Over the ensuing two days, the pt developed some nausea and vomiting and had continued watery diarrhea. He noted that he had no significant headache at that point, he did have some burning of his tongue and he developed dry cough. He did not recall any skin tenderness nor any arthralgias or arthropathy, no difficulty with urination and no abdominal pain. With his complaints of rash and fevers, he presented to the emergency dept on 5/24. Initial evaluation was notable for temp of 101.3, blood pressure of 116/65, respirations 16 and O2 Stat 95% on room air. He was noted to have a diffuse exanthem, mild injection of the conjunctiva bilaterally and a dry cough. Further eval included a WBC of 19.2 with an ANC of 17.2.  A comprehensive metabolic profile was notable for normal renal function, an AST of 45 and an ALT elevated at 75 and an alkaline phosphatase of 179. Two blood cultures were drawn, a throat culture was obtained and the pt was admitted The pt was seen by a dermatologist. No vasculitis was felt to be present. The pustules were found to be present on the trunk and again described as a folliculitis. Over the night, the pt had a temp as high as 103.9 and a mild dry cough. He was felt to have mild overall thrush and has been started on Mycelex. Today, the exanthem has taken on a sandpaper quality and appears to be increased along body creases. There is a marked desquamative quality to the rash especially in the axilla and groin. I was asked to see the pt regarding further thoughts on a differential diagnosis and antimicrobial management.