Cases reported "Exanthema"

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1/10. Miliary tuberculosis presenting with rigors and developing unusual cutaneous manifestations.

    We report a case of miliary tuberculosis presenting with high fevers and rigors. While undergoing evaluation, the patient developed a diffuse, erythematous, maculopapular eruption coalescing to form erythematous plaques involving the abdomen, trunk, and proximal extremities. Biopsies of the lesions were smear- and culture-negative for mycobacterium tuberculosis. Rigors are an unusual presenting symptom of miliary tuberculosis and have only been reported three times in the (post-antibiotic era) literature. chills have been reported to occur 28% of the time. This symptom can be confusing to the practitioner, leading to delay in diagnosis. The skin lesions were most consistent with a lichenoid tuberculid eruption. The patient had a negative purified protein derivative and non-reactive anergy panel, and the lesions involved only the cutis and healed without scarring. The patient had a dramatic response to antituberculous therapy, with resolution of the fever within 2 days and resolution of the rash within 2 weeks.
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2/10. Acute exanthematous pustular drug eruption induced by mexiletine.

    A 56-year-old man developed infiltrated erythemas on the trunk, extremities, and face with marked facial edema, one month after taking mexiletine hydrochloride for his arrhythmia. A number of pustules were also noted on the surface of erythemas on his chest and face. Laboratory examination showed liver dysfunction and hypereosinophilia. The culture from pustules was sterile. Histological examination of the biopsied skin from a pustular lesion revealed a subcorneal abscess, and perivascular infiltration of lymphocytes, mononuclear cells and eosinophils in the upper dermis. The skin lesions and facial edema as well were improved within three weeks by withdrawal of mexiletine hydrochloride. patch tests with 10% and 20% mexiletine hydrochloride in petrolatum showed positive reaction, however, pustules were not provoked on the tested site. We conclude that pustules, infiltrated erythema and facial edema were the signs of acute exanthematous pustular drug eruption induced by mexiletine hydrochloride.
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3/10. Focal and generalized folliculitis following smallpox vaccination among vaccinia-naive recipients.

    CONTEXT: With the reintroduction of smallpox vaccination, detailed contemporary descriptions of adverse reactions to the vaccine are needed to adequately inform the public and clinicians. During a multicenter, randomized controlled trial investigating the efficacy of various dilutions of smallpox vaccine, we observed the appearance of a papulovesicular eruption (focal and generalized) in study volunteers. OBJECTIVE: To characterize the papulovesicular eruptions by clinical, virologic, and histopathological characteristics. DESIGN, SETTING, AND PARTICIPANTS: Prospective case series of papulovesicular eruptions following smallpox vaccination in healthy, vaccinia-naive adult participants compared with noncases conducted from October 2002 to March 2003. Variables potentially related to these eruptions were collected retrospectively through chart review. Eruptions were described based on viral culture, clinical examination, and histopathological evaluation (1 biopsy specimen from 1 case). MAIN OUTCOME MEASURE: Cases of papulovesicular eruptions following vaccination. RESULTS: During the trial, of 148 volunteers (56% women; mean age 23.6 years), 4 participants (2.7%) developed generalized eruptions and 11 (7.4%) noted focal eruptions. Viral cultures of sample lesions were negative for vaccinia. The result of a skin biopsy sample from 1 case of generalized rash revealed suppurative folliculitis without evidence of viral infection. All lesions resolved without scarring. In the cohort, cases and noncases did not show significant differences in terms of sex, in the use of nonsteroidal anti-inflammatory drugs or oral or depo contraceptives, in medication allergies, in the incidence of fever or lymphadenopathy after vaccination, or in the dilution of vaccine received. CONCLUSIONS: folliculitis is a common and benign eruption observed in vaccinia-naive adult volunteers following smallpox vaccination. This eruption may be seen in volunteers receiving the vaccine in the newly instituted vaccination programs and may be met with heightened anxiety, potentially being confused with generalized vaccinia. This description of folliculitis using clinical, virologic, and histopathological findings should allay these concerns and provide additional insight into this eruption.
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4/10. brain abscess caused by salmonella enterica subspecies houtenae in a patient with chronic granulomatous disease.

    A 44-month-old boy with chronic granulomatous disease has been suffering from fever and skin rash for 7 days prior to admission. The blood culture obtained on admission revealed salmonella enterica subspecies houtenae. He received intravenous ceftriaxone therapy during his hospital stay and oral cefixime after discharge. Unfortunately, the same symptoms recurred 2 weeks after discontinuing cefixime and the culture from the aspirate of a skin nodule yielded the same microorganism again. He received intravenous ceftriaxone therapy after readmission and became afebrile 3 days later. However, focal seizure was noted on the 14th day of hospitalization. Brain magnetic resonance imaging revealed multiple brain abscesses, and electroencephalogram showed epileptiform activity. The intravenous antimicrobial agents were continued for a total of 84 days and interferon-gamma was administered as adjunctive therapy. Finally, he recovered from brain abscesses without any neurologic sequel. It is suggested that an extended course of antimicrobial treatment is necessary for chronic granulomatous disease with pyogenic infection because of the defective intracellular killing ability.
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5/10. urticaria, exanthems, and other benign dermatologic reactions to smallpox vaccination in adults.

    A phase 1 smallpox vaccine trial involving 350 adult volunteers was conducted. Of these subjects, 250 were naive to vaccinia virus vaccine (i.e., "vaccinia naive"). volunteers received a new cell-cultured smallpox vaccine or a live vaccinia virus vaccine. Nine self-limiting rashes (3.6%) were observed in the vaccinia-naive group. None of the vaccinia-experienced patients had a rash. Rashes appeared 6-19 days after vaccination and had 5 different clinical presentations. Five volunteers had urticarial rashes that resolved within 4-15 days, 1 had an exanthem that lasted 20 days, and 1 each presented with folliculitis, contact dermatitis, and erythematous papules found only on the hands and fingers. volunteers reported pruritus, tingling, and occasional headaches. Relief was obtained with antihistamine and acetaminophen therapy. No volunteer experienced fever or significant discomfort.
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6/10. Human monkeypox infection: a family cluster in the midwestern united states.

    BACKGROUND: The outbreak of monkeypox in the midwestern united states during June 2003 marks the first documented human infection in the Western Hemisphere. Consistent with those in outbreaks in africa, most cases in this outbreak were associated with febrile rash illness. We describe a cluster of monkeypox in a family with a spectrum of clinical illness, including encephalitis, and outline the laboratory confirmation of monkeypox. methods: Standardized patient information was collected by questionnaire and medical chart review; all cases described were laboratory confirmed. Laboratory methods included nucleic acid detection, viral culture, serologic testing, histopathologic evaluation, and immunohistochemical testing. RESULTS: Of 3 family members with monkeypox, 2 had rash illness only, and 1 required hospitalization for severe encephalitis. The family member with the mildest clinical course had previously received smallpox vaccination. Diagnostic testing by both polymerase chain reaction and culture revealed infectious monkeypox virus in skin lesions of all 3 patients; 2 patients had orthopoxvirus detected by immunohistochemistry in skin lesions. The patient with encephalitis had orthopoxvirus-reactive immunoglobulin m (IgM) in cerebrospinal fluid. All patients had detectable IgM responses to orthopoxvirus antigens. CONCLUSIONS: These 3 patients illustrate a spectrum of clinical illness with monkeypox despite a common source of exposure; manifestation and severity of illness may be affected by age and prior smallpox vaccination. We report that monkeypox, in addition to causing febrile rash illness, causes severe neurologic infection, and we discuss the use of novel laboratory tests for its diagnosis.
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7/10. Streptococcal toxic shock syndrome with initial manifestation of abdominal pain and cholecystitis.

    Streptococcal toxic shock syndrome with the initial manifestation of abdominal pain and cholecystitis is rare. We report the case of a 10-year-old boy who presented with abdominal pain, cholecystitis and shock initially. Acute respiratory distress syndrome, renal and hepatic insufficiency and disseminated intravascular coagulation developed soon after admission. skin rash and desquamation were found subsequently during the recovery phase. The blood and sputum cultures were sterile. Acute and convalescent plasma from the patient showed increased anti-streptolysin O titer (ASLO titer). Measurement of the ASLO titer on Day 11 after the onset of disease had an ASLO titer of 242 IU/ml (N latex ASL, Dade Behring Marburg GmbH, USA), and the ASLO titer on Day 21 after the onset of disease showed an increase to 875 IU/ml. These clinical findings and the plasma analysis were consistent with streptococcal toxic shock syndrome.
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8/10. Severe acute generalized exanthematous pustulosis in a pregnant woman.

    A 23-year-old woman was admitted to the Department of dermatology 4 days postpartum with multiple disseminated pustules. A week earlier, she had received 500 mg of amoxicillin with 125 mg clavulanic acid for pharyngitis. After three doses, she noticed the first pustules appear on the chest and back, and the antibiotic treatment was discontinued. Three days later, during the 37th gestational week, she delivered her second child prematurely, but in generally good condition. After delivery, her skin lesions began to spread, and the patient developed fever up to 39 degrees C (102.2 degrees F). Her medical history was significant for similar pustular lesions at age five, diagnosed as a bacterial skin infection despite negative skin cultures. Antibiotics were introduced with no clinical improvement over several months. Her skin lesions resolved after discontinuation of antibiotics. No personal or family history of psoriasis was present. On admission, generalized pustules and flaccid blisters with pus on an erythematous background were present (Figure 1). The patient complained of burning of the skin lesions and fever (38.2 degrees C [100.8 degrees F]) but was otherwise in good condition. Laboratory tests revealed leukocytosis (15,000/mL) with granulocytosis (82%) and an extremely high c-reactive protein level (323.4 mg/L; normal range, 0-7 mg/L). Bacteriologic culture of the pus was negative. The histopathology revealed a subcorneal blister filled with neutrophils and a few epidermal cells. In the dermis, a scant perivascular inflammatory cell infiltrate was noted (Figure 2). Direct immunofluorescence revealed small amounts of IgM at the dermoepidermal junction. Because of the very diffuse distribution of pustules, two doses of hydrocortisone 200 mg IV b.i.d. for 2 days was administered, followed by prednisone 40 mg q.d. with rapid tapering. Rapid improvement of skin lesions was observed and the patient's skin practically cleared within 7 days. Corticosteroids were discontinued after 14 days.
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9/10. food-induced acute generalized exanthematous pustulosis in a pregnant woman.

    A 21-year-old woman of Romany origin, in the third trimester of her fourth pregnancy, was admitted to the hospital because of a generalized erythematous and pustular eruption and desquamation involving her face, neck, trunk, and extremities. The skin changes were accompanied by fever (100.4 degrees F [38 degrees C]) and malaise. The patient was convinced that the dermatitis was induced by the consumption of "spoilt" pork sausage (bad smell, changed taste) approximately 24 hours earlier. Clinical examination revealed a woman with phototype III skin, black eyes, and black hair, in good general health. Widespread, symmetrical, moderately intense erythema and isolated or coalescing targetoid lesions studded with discrete, pinhead-sized, nonfollicular pustules in the center or at the periphery were distributed over her face, trunk, groins, and upper and lower extremities (Figures 1). On the neck and abdomen, lamellar desquamation was observed (Figure 2). Palms, soles, scalp, mucous membranes, hair, and nails were not affected. Nikolsky's sign was negative. The patient complained of very slight skin burning and itching. The pregnancy was proceeding without any complications and her obstetric status was normal. The woman had neither any accompanying diseases, nor previous personal or family history of psoriasis, nor any known allergies. She had taken no systemic medication (not even vitamins). She had three pregnancies; two ended with the delivery of healthy babies and one of them was aborted at her will. Laboratory studies revealed leukocytosis (13.2 x 109/L), neutrophilia (8 x 109/L), anemia (hemoglobin, 108 g/L), and an elevated erythrocyte sedimentation rate (68-110 mm/h). The results from the following investigations were normal: urinalysis, renal and hepatic function, serum albumin, Ca, Na, K, aspartate aminotransferase titer, cryoprotein, hepatitis b surface antigen, and serum markers for syphilis. Bacterial and fungal cultures of pustular content were sterile. A skin biopsy specimen of lesional skin revealed subcorneal pustules containing leukocytes and necrotic keratinocytes and a mixed perivascular inflammatory infiltrate with isolated eosinophils in the dermis (Figure 3). The patient was treated with systemic methylprednisolone in gradually reduced doses, fluocinonide cream 0.05%, and emollients. As a result, her fever disappeared and her erythema faded. Frequent obstetric examination and cardiotocography were normal and showed no evidence of placental insufficiency. At 40 weeks' gestation, the patient spontaneously gave birth without any complications to a healthy boy. She was discharged with complete resolution of the skin lesions, preceded by massive desquamation of the epidermis. The 1-year follow-up of the patient revealed no relapses or new pustular eruptions.
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10/10. arcanobacterium haemolyticum pharyngitis and exanthem. Three case reports and literature review.

    BACKGROUND: arcanobacterium haemolyticum is a bacterial pharyngeal pathogen that infects adolescents and young adults, frequently causing an exanthem that may mimic a viral exanthem, toxic erythema, or drug eruption. To our knowledge, the cutaneous manifestations of A haemolyticum infection have not previously been reported in the dermatologic literature. OBSERVATIONS: The severity of this infection can range from mild pharyngitis to a diphtheria-like illness and even septicemia. We report three cases that demonstrate the spectrum of manifestations of this disease, including an unusual case with acral distribution of the associated exanthem. CONCLUSIONS: arcanobacterium haemolyticum infection should be considered in the differential diagnosis when evaluating a young adult with an exanthem. Antibiotic treatment is reliably efficacious, but the throat swab must be specifically cultured on 5% human blood agar in order to make the diagnosis.
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