A Case Presenting with Atypical Rash

Dr. Fazlul Haque, Dr. Nazmul  Kabir Qureshi, Dr. Zeenat Sultana, Dr. P R Saha, Dr. Iqbal Hossain, Dr. Nazmul Islam, Dr. Afsana Begum.

Department of  Medicine, United Hospital .

A  17 year old male was admitted to the Medicine Department of UH on 19-04- 13 with the complaints of high grade intermittent fever, joint pain, multiple rashes of variable colour and size over both lower limbs for a duration of 8 days.  Prior to this illness, he had sustained injury to his right ankle for which he took NSAIDs and Cephadrine but after 2 days he developed his current illness along with loose motion. He was treated  with Roxithromycin and pivampicillin and his symptoms subsided.   

 On admission he was conscious and oriented, pulse-110, BP-130/80 mmHg, Temp-102 F.  There were multiple tender rounded papulo-vesicular hemorrhagic rashes of variable size with erythematous base; some had blackish necrotic  bases distributed in both upper and lower limbs.  His right ankle was swollen, warm, tender and the overlying skin was erythematous. Rest of the physical examination were normal. 

Lab. Reports revealed: TC WBC- 12.4 X 10 3 / uL,  ESR-62mm,  CRP-80 mg/L, ANA, C-ANCA & P-ANCA- negative.  IgE 1643 IU/L.  Based on this information the patient was diagnosed as a case of Erythema Multiforme-- an acute, self limited and sometimes recurring skin condition that is considered to be a type IV hypersensitivity reaction associated with certain infections (Streptococci, Staphylococci, Mycoplasma, Viruses ), Medications- Penicillin, Cephalosporins, Allopurinol, Aspirin and others), other various conditions e.g. Collagen disease, Vasulitides, Leukemia, Lymphomas etc. Skin biopsy is often needed in difficult cases. Complications are Cellulitis,  Sepsis, Septic Shock, Pneumonitis, Myocarditis, Hepatitis, Nephritis etc.

Treatment of Erythema Multiforme include Steroids, IV Immunoglobulins, Supportive measures, and often antibiotics. Our patient made a full recovery within a week.