Hot Seat #27 Denouement: Spreading arm rash

By Kaynan Doctor, Children’s National
With Lili Moran, Children’s National, on the Hot Seat
Edited by Jen Anders, Johns Hopkins

The Case
This is a challenging case about an 8 year-old girl who had a non-blanching rash spreading over her arm down to her wrist over 5-6 days. The picture is below. For a complete case presentation, click here to go to the original post.

Clinical Pearls
Thanks to Dave Mathison, Sabah Iqbal, Jennifer Chapman, and Paul Mullan, all faculty from Children’s National for adding your clinical opinions and Lili Moran for sitting on the Hot Seat this week. Several people wanted more history, specifically about travel, swelling, and trauma. The consensus was that this was unusual. Click here to read more of their clinical reasoning. 

“Sometimes history is wrong and then we get fixated on the parental history … as absolute truth.” –Paul Mullan

“If it's not going towards the lymph nodes, then that probably excludes many of the weird organisms that climb the lymphatic chain.” –Dave Mathison

“W.E.I.R.D!” –Sabah Iqbal

“Given that the direction of spread doesn't fit other disease patterns, I am going to throw out the idea that this is from trauma- self-inflicted if the child is anxious or depressed, or inflicted by parents (intentional injury or treatment such as coining, though coining is usually on the back).” –Jennifer Chapman

“If I saw this kid in Africa, dropped off on the clinic bench when no one was looking (this happened somewhat frequently while parents ran errands), without a translator and the kid was giving me the "I don't know how this happened look", I'd assume this well looking kid was getting bullied by some neighborhood kid.” –Paul Mullan

“Weird skin things often make me think of non-tuberculosis mycobacterium.” –Dave Mathison

“My instinct is to try an NSAID and admit for 24 hours of antibiotics - just to watch for progression (or resolution) of symptoms.” –Sabah Iqbal

“My vote would be for:
1) more history (exposures, travel, etc)
2) PO antibiotics
3) ppd
4) don't think additional labwork is all that helpful in the absence of true systemic disease or localized lymphadenopathy
5) no imaging
6) f/u with infectious diseases if no improvement
7) return to ED if signs of systemic disease (fever, satellite lesions, etc)”
-Dave Mathison

Here’s how you answered our questions (n=22)
1. At this point, which of the following is highest on your differential?

Most people put phlebitis high on their differential although the next segment didn't like any of our choices. No one thought it was an allergic reaction.



2. Which of the following do you think would provide the most useful information?
 
There was a dichotomy of responses here. The largest proportion of people thought an ultrasound of the arm would be useful but the next biggest group said that no labs or tests were indicated. Everyone agreed that a basic metabolic panel would not be the most useful thing here.

3. It’s 2 am and time to sign out. What is your disposition decision for this patient?

Most people would have signed this patient out to the overnight person to have the patient get an ultrasound in the morning. An almost equal number would have sent this child home after waking up the PMD and admitted outright. Only a few people would have left their disposition up to their consultant.
 

From the Hot Seat
by Lili Moran, Children's National

Like Dave, my initial thought was phlebitis or lymphangitis, but the fact that it was going in the wrong direction threw me too. I actually googled distally progressing phlebitis and came up with nothing, just looking for strange case reports, etc. The initial bruise could be a nidus for some sort of clot or phlebitis, but I don't know why it's spreading distally. 

If she only has mild tenderness at the site of the rash, but it doesn't affect any ROM of the arm, I guess it has to be more superficial than a DVT would be. I think my initial gut reaction would be to get some labs (coags, CBC). My inclination would be to figure out what is going on before disposition of the patient. If it were during the day, I would probably like to consult dermatology for their opinion. At night, I would either ETU or admit her for observation of progression and a consult in the morning. 

I like Jen and Paul's ideas about bruising/coining/NAT. I think getting a better history is going to be the key to solving this case. I've never heard of coining on the arm, but I guess it's a possibility if the parents were trying to do something for the initial bruise that was there. I'm sort of itching to touch the rash myself, but it is described as macular, so I guess there is no palpable "cord" or areas of hematoma collection, making venous processes less likely as well. I think my final answer would be better, more detailed history, as Paul said, taken from each individual in the family, checking labs, consulting dermatology, and admitting for observation if I can't figure out what it is. Also, the arm itself looks like it belongs to a teenaged boy, not an 8 YO girl, but I would completely undress the patient and look for any other lesions, bruises, etc.

Denouement
by Kaynan Doctor, Children's National

CBC and coagulation studies, CMP, ESR and CRP were sent in the ED and were unremarkable. With the possibility that this could be an unusual presentation of a DVT, she also underwent a duplex scan of the right arm which revealed no thrombosis. One of our thoughts was that this could be a thrombophlebitis as Dave had mentioned however with no elevation in inflammatory markers this seemed less likely. 

No antibiotics were started on her. The family is from Tanzania originally but had no recent travel. Furthermore on repeat conversations with both parent (including calling them back a week later) they seemed appropriate and concerned and their histories were congruent. The child also could not identify the cause of her injuries when taken aside.

As Paul mentioned regarding consulting Dermatologty: A picture of the rash was sent to dermatology by text message on the day of the visit. They agreed to see the patient, post discharge from the ED in their clinic. The patient was started on topical clobetasol and found that the rash disappeared completely after 5 days. However 24 hours later the rash returned but now was extending from the elbow to the wrist. The patient was recently seen in dermatology clinic and a biopsy result indicates hemorrhagic areas of the subcutis and a minimal perivascular inflammatory infiltrate. Dermatology are still reserving their opinion as to what may have caused this but based on their discussions it is possible that the rash may have been due to local trauma/self-inflicted.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations but is on leave. This week's case was guest edited by Jennifer Anders, faculty at Johns Hopkins. We welcome your commentary.