Paper
Case records of the Massachusetts General Hospital. Case 34-2009. A 20-year-old man with sore throat, fever, and rash.
Published Oct 29, 2009 · C. Taylor, L. Duncan, J. Handwerker
The New England journal of medicine
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Abstract
Dr. Robert W. McGarrah (Medicine): A 20-year-old man was admitted to this hospital because of sore throat, fever, and a diffuse rash. The patient had been well until approximately 4 weeks earlier, when sore throat developed. On examination by his internist, vital signs were normal, the temperature was 36.8°C, and there was pharyngeal erythema without cervical lymphadenopathy. A rapid streptococcal-antigen test was negative. The next day, he felt better. One week before admission, sore throat and fever recurred, and the patient returned to his internist the next day. The temperature was 37.1°C and the pulse 102 beats per minute; he appeared well. The tonsils were enlarged (3+), with exudate and petechiae, and there was shotty bilateral cervical lymphadenopathy. A rapid test for streptococcal pharyngitis and a blood test for mononucleosis were negative. Amoxicillin–clavulanate was prescribed. The next day, 1 day after beginning the antibiotic therapy, a flat, red, even, itchy rash developed on the medial surface of his right arm, which he thought was poison ivy. During the next 3 days, the lesions became raised, enlarged, and painful and spread from his arms to his legs, back, hands, feet, and perioral area, without mucosal involvement. He took ibuprofen for the pain. Two days before admission, the patient returned to his primary care provider, who noted a generalized papular rash and sent him to the emergency department of a hospital near his home. Repeat testing for streptococcal pharyngitis was negative. Results of other tests are shown in Table 1. The administration of antibiotics was stopped, and a prednisone taper (starting dose, 40 mg) was begun. The fevers resolved, but the sore throat and rash persisted and then worsened; he saw his internist, who sent him to the emergency department of this hospital. The patient reported that the rash had evolved to large, painful, hemorrhagic vesicles and bullae that covered most of his body surface; the bullae frequently ruptured, leaking blood and clear fluid. He had odynophagia for solid foods, mild fatigue, swollen lymph nodes in his neck, and loose stools for approximately 4 days. He reported a weight loss of approximately 3 kg, because of pain and difficulty swallowing solids. He did not have headache, stiff neck, confusion, cough, rhinorrhea, abdominal pain, nausea, vomiting, joint aches or effusions, or difficulty breathing. He had had varicella as a child, and he reported that the lesions had appeared smaller and more diffuse than the current presentation. He had a history of alCase 34-2009: A 20-Year-Old Man with Sore Throat, Fever, and Rash
Case ReportA 20-year-old man developed a rash and fever after starting antibiotic therapy, but the cause was not identified until he was admitted to the hospital.
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