Age: 76.0
Sex: M
Vaccine: FLUX
Symptoms: Rash papular, Red blood cell count decreased, Red cell distribution width normal, Skin exfoliation, Skin tightness
Clinical narrative: S:  Pt is here with chief complaint of rash-present for the past 2 days, this is day # 3, reports it started the next day after starting the ranitidine, he reports he didn't get it right away, and was taking the naproxen without any stomach problems but started the ranitidine as ordered and placed in his med box, and now doesn't know which pill.  The rash has gotten worse each day, is on all of body "except his toe nails", and he laughs. Allergies:  POLYESTER From PA note 1/27/10 after multiple visits to PA and NP plus consult to dermatologist. Ranitidine was ruled out. Zostavax was never ruled as a cause.  This is only coincidence that this submitter felt needed to be reported. "After admission, on approximately 12/26/09, he developed symptoms of pruritis and appearance of pink papular rash which quickly became more confluent. This was first called to attention of this provider on 12/29/09. This was initially thought to be possible atopic reaction to oral ranitidine which was discontinued. Veteran verifies he wears only 100% cotton clothes/underwear due to his allergy to polyester. He had no constitutional symptoms of fever, nausea, vomiting, diarrhea, vital signs remained normal. At one point at least 2 weeks later, he reported "my throat might have been sore for a day or two." He was put on an oral prednisone taper. Over the years, he had had similar episodes of "unexplained rashes" and was even seen in dermatology MD in 2007. No distinct etiology was ever found for his intermittent outbreaks of "red skin and itch". The syndrome was called "erythroderma" by dermatologist. Records were  scanned. In early January, his rash progressed to involve most of his trunk and extremities, neck and lower check. He never had swelling or intra/extraoral involvement. By this time, all of his oral medications except prednisone and doxepin to help pruritis at night had been discontinued. He continued to use hypoallergenic topical moisturizers.  On 1/6/10, the skin overnight become markedly red, taut, shiny, with involvement palms and soles. The rash was entirely confluent up to his lower jaw/earlobes. Above that, he had some pink and peeling skin. At this time, he was sent to Urgent Care where he had lab testing that later revealed elevated ASO titer 380, normal C3 118 and elevated C4 of 54. A throat culture came back negative, there was never a clinical appearance related to strep throat. There was suspicion for  Group A strep colonization/"scalded skin syndrome" causing his skin changes and he was put on a 14 day course of oral penicillin which has been completed at time of discharge. Refer to notes by authors (name removed) PA-C and (name removed), PA-C for additional information. On his skin, there were never any bullae/blisters/fissures. Within several days, profuse peeling of skin began over his entire body, including genitals. He did develop some superficial excoriations on posterior calves from scratching. These were healing well at time of discharge and peeling was almost gone.