Case 3: Rash and Fever in a 12-year-old Girl

Presentation

A 12-year-old girl transfers to your inpatient service with a 5-day history of fever and rash. Initial symptoms included soreness under the left axilla associated with chills and a low-grade fever (100.5°F [38.1°C]). Repeated visits to multiple physicians yielded a diagnosis of viral syndrome due to nonspecific findings on examinations and negative results of radiography of the left shoulder and streptococcal rapid antigen testing. The soreness progressively worsened, with rapid development of a red, sunburnlike rash spreading from the axilla to the torso. Development of this rash coincided with abrupt onset of fever (up to 103.5°F [39.7°C]), headache, chills, and several episodes of vomiting the day of initial admission to the transferring hospital. Owing to the vomiting she was started on intravenous piperacillin/tazobactam to treat scarlet fever. Despite some improvement in symptoms after several days of intravenous antibiotics, the patient is transferred to your service to be seen by an infectious disease specialist due to uncertainty of diagnosis.

Physical examination reveals a cooperative, but uncomfortable, girl. Her temperature is 97.9°F (36.6°C), pulse rate is 105 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 116/66 mm Hg. The rash is erythematous, mildly edematous, and nontender, and it feels like sandpaper. Her skin is peeling at the tips of her fingers and toes. She is unable to abduct her left upper extremity due to soreness in the axilla and adjacent chest wall. …