REASON FOR CONSULT: Pruritic rash.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man, originally from (XX), with a history of tuberculosis and lymphatic infection 11 years ago for which he completed treatment, who presents to the emergency department with 2-3 weeks of diffuse pruritic maculopapular rash.
Rash initially involved both hands, including palm area and neck, progressing to diffuse body rash, sparing facial area. The patient reports no previous similar events. He has been in contact with fiberglass particles at his construction work and used new cloth detergent approximately 2 weeks ago, which coincides with development of rash.
Denies fevers, chills, nausea, vomiting, diarrhea, dysuria, night sweats, loss of weight, decreased appetite, respiratory symptoms, sick contacts or travel.
He received prednisone 60 mg x1 and Benadryl 25 mg x1 in the emergency department with good symptomatic relief.
REVIEW OF SYSTEMS: All other components of review of systems are negative or as described in history of present illness.
PAST MEDICAL HISTORY: Mycobacterial infection treated 11 years ago, right foot surgery for removal of an accidentally included wood piece.
FAMILY HISTORY: Father died of complications of asthma.
SOCIAL HISTORY: Born in (XX), immigrated to the United States 7 years ago. Lives in (XX). Construction worker. Denies drug, tobacco or alcohol use. He is not sexually active. Last sexual partner was approximately 2 years ago. Reports consistent use of condoms. No prior HIV test. Vaccinations are up-to-date.
ALLERGIES: No known drug or food allergies.
MEDICATIONS: Prednisone 60 mg p.o. x1, Benadryl 25 mg p.o. x1.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: Thin man, resting comfortably in bed, in no acute distress.
VITAL SIGNS: Blood pressure 124/82, heart rate 60, respiratory rate 18, temperature 97.6 and pulse oximetry 100% on room air.
EYES: No icterus. Pink conjunctivae without petechia.
ENT: Clear tympanic membranes and nasal turbinates and oropharynx.
NECK: Bilateral neck fullness. Supple.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Nondistended, bowel sounds present, nontender and soft. No organomegaly.
GENITOURINARY: No open lesions. Normal sized penis and testes. No ureteral discharge.
LYMPH: No neck, supraclavicular or axillary lymphadenopathy.
BACK: No pain on palpation of vertebral processes or costovertebral angles.
MUSCULOSKELETAL: No joint effusion, warmth. Full range of motion throughout.
VASCULAR: 2+ throughout.
SKIN: Dry skin with diffuse maculopapular rash and excoriation, sparing face. No open lesions, ulcerations, scaling skin or discharge.
NEUROLOGICAL: No gross neurological deficits.
PSYCHIATRIC: Alert and active. Appropriate.
LABORATORY DATA: Sodium 131, potassium 3.8, chloride 102, CO2 31, anion gap 6, glucose 79, BUN 11, creatinine 0.89, calcium 9.0. Total bilirubin is 0.5, AST 33, ALT 26, troponin 0.01, LDH 339, amylase 106. WBC 3.1, hemoglobin 15.7, hematocrit 45.4, platelet 170,000, segmented cells 43, bands 2, lymphocytes 25, reactive lymphocytes 2 and eosinophils 17.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman with 2-3 weeks of diffuse erythematous maculopapular rash with facial sparing. After carefully obtaining detailed history, he seems to have clear exposure to possible offending agents, including fiberglass, new detergent and possibly bed bugs. Rash is consistent with an allergic dermatitis rather than an infectious process. Although involvement of palms and soles can be seen in certain infectious process as syphilis and viral syndrome, we think history is more consistent with allergic reaction, which is supported by the presence of elevated eosinophils. We think main therapy would consist of remove offending agents along with the application of topical steroid cream and antihistaminic therapy for symptomatic relief. We agreed with RPR for evaluation of syphilis.
RECOMMENDATIONS:
- Obtain RPR – syphilis IgE.
- Remove offending agents.
- Topical steroid cream and antihistaminic.
- Follow up with primary care or Dermatology if no improvement in 1 week.
Thank you for this consultation. Please contact infectious disease team if any questions or changes in the patient’s clinical status. Recommendations discussed with the emergency department team and handwritten note placed in the patient’s medical records.
