with Lili Moran, Children's National on the Hot Seat
edited by Jen Anders, Johns Hopkins
The Case
8 yo previously well female presents to the ED with a linear non blanching rash that started at the medial aspect of her right upper arm near the shoulder and has spread over 5-6 days to her wrist (see picture below). Patient denies any recent trauma. She only recalls picking or scratching the area where the bruise started prior to noticing the rash. The rash is painful but does not hinder her from her regular activities. There have been no other injuries or similar rash elsewhere. No history of a tick bite, no new topical creams or detergents. She was seen by her PMD 3 days prior and a CBC was sent which was unremarkable.
Review of systems: negative for fevers, difficulty breathing, abdominal pain, diarrhea, or vomiting.
Past Medical History: Unremarkable
Family History: negative for rheumatological conditions, hypercoagulable state or bleeding disorders in the family.
Social History: No recent travel abroad.
Examination
Pulse 76, BP 113/64, RR 22, SpO2 100% RA, T:37.5 Wt 33.6 kg
Picture of rash appears here:
Questions for you (click vote to see what others said)
If you got any labs or x-rays, they were normal. Ultrasound is not available until the morning.
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Click here for the denouement.
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series but she is on a well-deserved leave. During her absence, faculty from Children's National, Inova Fairfax, and Johns Hopkins will serve as case editors. Jennifer Anders, Johns Hopkins, edited this case.
My first instinct is that this is lymphangitis or thrombophlebitis which are often underwhelming diagnoses but sometimes interesting. Both need antibiotics and more history to exclude weird organisms (sporotrichosis, nocardia, etc). BUT.... lymphangitis/thrombophlebitis usually spread in the opposite direction from hand up the extremity towards lymph nodes, rather than prox->distal like in this case. So i think that's a big red (weird) flag in this case. i would want to know if there was really no lymphadenopathy (localized primarily) and would get more history about travel and exposures.
ReplyDeleteSo a linear painful, purpuric rash that spreads prox->distal. hmmm. if it's not going towards the lymph nodes, than that probably excludes many of the weird organisms that climb the lymphatic chain. But i think that filariasis occurs in the opposite direction of most lymphangitis (like in this case) but that sounds really unlikely in somewhat without travel. Weird skin things often make me think of non-tuberculosis mycobacterium.
So 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)
W.E.I.R.D!
ReplyDeleteMy initial thought as I read this was phlebitis, but the picture looks much more dramatic than any phlebitis I've seen - in my experience, there's erythema and tenderness over the vein, but not frank bruising. That's just odd...
Still, without any further weird history (travel, etc, per Dave above), my instinct is to try an NSAID and admit for 24 hours of antibiotics - just to watch for progression (or resolution) of symptoms... I worry a little about rare organisms, so hopefully, watching while we treat can help delineate between an interesting presentation of a common condition and a rare disease masquerading as a common condition...
When I expand the picture more, the rash looks more superficial and not like a deeper process (was thinking of vasculitides such as lupus). So, 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).
ReplyDeleteSomething's not right with this story. Probably the proximal to distal part. Sometimes history is wrong and then we get fixated on the parental history (sometimes we're convinced the parents are wrong though, and they're right, but that's another story) as absolute truth. 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.
ReplyDeleteLooking at the lesions, they're all separated. And they seem to be macular/purpuric "paired" ovals with one half of the oval darker than the other. This makes me think the kid is getting pinched with two fingers (distal phalanx of thumb and middle phalanx of 2nd finger) with equal force but since the thumb has lower surface area than the 2nd finger, you get more pressure per square inch and so one half appears darker and more circular than the more oblong other half, with "normal" unbruised skin between. It's tender because it's a bruise. I didn't hear anything about swelling or warmth in the hx, assumedly because they weren't there.
Who's doing this to him?
Not likely an atypical bug: no cutaneous larva migrans (unlikely as lesions not serpiginous and "connecting" to one another; the "not connecting" part also makes me think not lymphangitis); unlikley rickettsial as should be more diffuse petechiae, b/l, etc.
Keep taking vital signs, outline the lesions so you know if it's truly progressing or not, figure out who else lives with him, talk to him with parent(s) outside the room, etc. If this theory doesn't pan out on hx, then consider derm c/s in ED (by phone) or in AM.
Like Dave, my initial thought was phlebitis or lymphangitis, but the face 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 heart of coining on the arm, but I guess it's a possibility if they 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" the lesion, 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.
ReplyDelete