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May 2008
By Brian Rike, MD, Thomas Payton, MD, Kirkland Lau, DO, and Stephen M. Schleicher, MD
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CASE:
A 17-month-old girl presents to your emergency department with a rash and a fever. The rash began on her chest and abdomen three days ago and has progressed to cover her back, chest, abdomen, extremities, and face. She was seen by her pediatrician about 10 days ago, diagnosed with otitis media, and started on amoxicillin. Her parents tell you she has had swollen knees and ankles for the past two days as well as hesitancy ambulating. She has a fever of 101.5°F taken rectally and is mildly tachycardic. Physical exam confirms swollen and tender knees and ankles. There does not appear to be any mucous membrane involvement.
WHAT IS YOUR DIAGNOSIS? |
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This child is exhibiting a serum sickness-like reaction to amoxicillin. Patients usually present with rash, fever, polyarthralgias or polyarthritis, refusal to walk, lymphadenopathy, and abdominal pain. Symptoms generally start one to two weeks after exposure to the causative agent—typically an antibiotic and most commonly cefaclor. Trimethoprim-sulfamethoxazole, penicillin, amoxicillin, and other cephalosporins may also provoke such reactions. The differential diagnosis includes Kawasaki disease, connective tissue disorder, erythema multiforme, Stevens-Johnson syndrome, Still disease, rheumatic fever, and meningococcal or gonococcal infection. The condition is usually self-limited and has an excellent prognosis. Treatment typically consists of antihistamines, nonsteroidal anti-inflammatory drugs, and a short course of corticosteroids in severe cases.
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Dr. Rike is a resident and Dr. Payton is an attending physician in the department of emergency medicine at Geisinger Medical Center in Danville, Pennsylvania. Dr. Lau is an associate with a division of DermDx Centers for Dermatology in Sinking Spring, Pennsylvania. Dr. Schleicher is director of DermDx Centers and a clinical instructor of dermatology at the Philadelphia College of Osteopathic Medicine, at Kings College in Wilkes-Barre, Pennsylvania, and at Arcadia University in Glenside, Pennsylvania. He is also a member of the EMERGENCY MEDICINE editorial board.
Emerg Med 40(5):43-44, 2008
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