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Question: Fever + Rash
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You are seeing a 3 year old ill-appearing child with high fever and rash. She initially started with tender erythema in her skin folds, progressing over the next 48 hours to diffuse erythema with flaccid desquamating bullae and yellow crusting around the eyes and mouth. Nikolsky sign is positive. There is no mucous membrane involvement. She was given ibuprofen at home after onset of the fever.
Kelly October 6, 2021 - 8:33 pm
B) IV Vancomycin. The patient’s vignette is most consistent with staphylococcal scalded skin syndrome, which should be treated with an antistaphylococcal antibiotic that covers MRSA. Differential diagnosis includes: Kawasaki disease, which is treated with IVIG (but there is no mention of prolonged fever or other findings of Kawasaki), toxic shock syndrome, which is treated with a combination of broad-spectrum anti-staph and anti-strep antibiotics + an antibiotic that reduces toxin production such as clindamycin (but TSS has a negative Nikolsky sign, and no facial crusting or desquamation), and Stevens-Johnson syndrome, which is treated by stopping the offending agent, often a medication, and often by management in a burn center (but lack of mucous membrane involvement points away from this diagnosis). Clindamycin is sometimes added in treating SSSS for its potential effects on toxin production, but is not recommended as a solo treating agent.