Visual Diagnosis

Presentation

A 10-year-old obese girl presents with fever and combative behavior during the past 2 hours. According to the patient’s mother, the girl had experienced fatigue the night before admission and developed fever the following morning. By that afternoon, her parents became increasingly concerned about her agitated mental status and called emergency medical services.

In the emergency department, she is disoriented and uncooperative. Her vital signs are notable for a rectal temperature of 41°C, pulse of 187 beats per minute, blood pressure of 108/79 mm Hg, respiratory rate of 25 breaths per minute, and oxygen saturation of 78% on room air. On physical examination, her skin is cold and clammy and capillary refill is 10 seconds. A tender 1 × 1-cm area of ecchymosis is noted over her left lateral breast, which the parents had not noted previously.

She is aggressively resuscitated with isotonic fluids, and blood cultures are drawn. Broad-spectrum antimicrobial coverage with vancomycin, clindamycin, and piperacillin-tazobactam is initiated. She is intubated for hypoxemic respiratory failure and shock. A urinary catheter is placed, and minimal urine output is noted. Within 6 hours of initial presentation, she requires intravenous dopamine and epinephrine for hemodynamic support.

Laboratory tests reveal the following abnormalities: pH 7.03; Pco₂, 40 mm Hg; bicarbonate, 10 mmol/L; creatinine, 2.01 mg/dL; lactate, 7.8 mmol/L; aspartate aminotransferase, 81 U/L; alanine aminotransferase, 43 U/L; white blood cells, 6900/cumm, with 81.5% neutrophils (20% bands), 10.7% lymphocytes, 7.2% monocytes, and 0.6% eosinophils. The ecchymotic area rapidly expands, and a bullous lesion appears within the area (Fig 1). A clinical diagnosis is made.