Case 1: Fever, Conjunctivitis, Rash, and Genital Lesions in a 17-year-old Boy

Molly McGetrick; Mary Katherine Siebenaler

doi:10.1542/pir.2018-0217

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Molly McGetrick, MD*,^†
Mary Katherine Siebenaler, MD*,^‡

^*Department of Pediatrics, University of Florida, Gainesville, FL
^†Division of Critical Care, Department of Pediatrics, University of Texas Southwestern, Dallas, TX
^‡Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL

AUTHOR DISCLOSURE
Drs McGetrick and Siebenaler have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Editor’s Note

Each year, the American Academy of Pediatrics’ Section on Pediatric Trainees hosts a case presentation competition at the National Conference & Exhibition. This month, we include 2 winning cases in our Index of Suspicion collection. Enjoy!

Philip R. Fischer, MD

Associate Editor, Index of Suspicion

Presentation

A 17-year-old boy presents to the emergency department with a 5-day history of persistent fever and cough followed by severe mouth pain, conjunctival injection, and periorbital erythema. Four days earlier he was prescribed azithromycin for suspected “walking pneumonia.” After beginning therapy he developed lip swelling, blistering of his buccal mucosa, and worsening conjunctival injection associated with yellow discharge. He continued taking the medication as prescribed, and his cough improved but the fever persisted. On further history, he denies a history of oral ulceration, sexual activity, and recent medication use other than azithromycin and ibuprofen.

On physical examination he is febrile to 102.4°F (39.1°C) with normal oxygen saturation. His lips, buccal mucosa, tongue, and soft palate contain several scattered, friable ulcers and dark, fluid-filled blisters (Fig 1). There are no tonsillar exudates. Exudative, bulbar conjunctivitis is noted bilaterally (Fig 2), but a dilated ophthalmologic slit lamp examination does not show evidence of uveitis. The remainder of his examination findings, including auscultation of all lung fields, are normal at this time.

Figure 1.

Visible ulcerations on the patient's lips, tongue, and buccal mucosa.

Figure 2.

Exudative conjunctivitis on initial presentation.

Initial laboratory results include an elevated highly sensitive C-reactive protein level of 120 mg/L (1,143 nmol/L), a white blood cell count of 12,200/μL (12.2×10⁹/L) with 87% neutrophils and 6.5% lymphocytes, a hemoglobin level of 14.6 g/dL (146 g/L), and …