Adolescent With Rash and Cough
Article Outline
[Ann Emerg Med. 2008;52:606.]
A 12-year-old girl from rural Indiana presented to the emergency department for temperature of 40°C (104°F), cough, and a painful rash on her legs. Her symptoms began 1 month previously with cough and fever, with subsequent development of rash. Evaluation revealed a nontoxic, well-developed 12-year-old. She had a pulse of 142 beats/min, respiratory rate of 18 breaths/min, blood pressure of 110/67 mm Hg, and room air oxygen saturation of 99%. Her physical examination result was notable for anterior cervical adenopathy and tender erythematous nodular lesions on her lower extremities (Figure 1). Chest radiograph and chest computed tomographic scan are also included (Figure 2, Figure 3).
Figure 1.
Nodular skin lesions.
Figure 2.
Pulmonary nodule, right lung, on chest radiograph.
Figure 3.
Parenchymal airspace disease and perihilar lymphadenopathy on chest computed tomographic scan. Used with permission of Elizabeth Weinstein, MD, Department of Pediatrics and Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN.
Diagnosis
Erythema nodosum associated with pulmonary histoplasmosis. Histoplasma capsulatum is a dimorphic fungus that is endemic in the Mississippi and Ohio River Valley. Its reservoir is soil contaminated by bird or bat guano. Clinical manifestations of infection are rare, with less than 1% of those infected presenting with symptoms.1 Histoplasmosis is primarily a pulmonary disease presenting as any of the following: acute pulmonary histoplasmosis, chronic cavitary pulmonary histoplasmosis, granulomatous mediastinitis, or mediastinal fibrosis. Rarely, patients may present with life-threatening disseminated disease.1, 2 Treatment with steroids or other immunomodulators during infection increases the risk of dissemination.1 Erythema nodosum, a self-limited panniculitis most frequently appreciated in the pretibial region, may be associated with histoplasmosis in the absence of disseminated disease.3 Although treatment is not needed for most patients with acute histoplasmosis, severe pulmonary or disseminated disease should be treated with amphotericin B. Mild to moderate pulmonary or disseminated disease should be treated with itraconazole.1
References
For the diagnosis and teaching points, see page 615.
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PII: S0196-0644(08)01462-5
doi:10.1016/j.annemergmed.2008.06.468
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
