PMLE

HPI: Previously healthy 19yF with "rash and not feeling well." The rash began 10 days ago. She describes it as red, starting on her arms and upper chest and spreading to her face and almost all of her whole body including her upper gluteal area and legs. It has come and gone since that time; however, she continues to not feel well, including headaches, some mild abdominal cramping, feeling hot but never having a temperature greater than 100, and intermittent itchiness of the rash. The patient has been seen twice at Campus Health and once by PCP. She was prescribed prednisone 8 days ago, which she finished a course of, but this did not improve her symptoms. She was prescribed 30 mg daily. She had seen a primary care physician in the last day, and he had decreased the dose to 20 to begin weaning. Campus health had collected urine, which they had called and said it had some bacteria in it, and they were sending for a culture; however, she denies any UTI symptoms. They had also done a normal pregnancy test. The patient also endorsed having 2 episodes of emesis last week, and continues to have some nausea. She had 1 watery stool. Her last period being 3 weeks ago. She is concerned because the rash is not getting any better.

VITAL SIGNS: Temperature is 99.1, heart rate 75, blood pressure 134/94, respiratory rate 18, satting 99% RA

wt 25%, ht 50%

GENERAL: The patient is sitting in bed, well developed, well nourished, no acute distress.

HENT: Normocephalic, atraumatic, moist mucous membranes with no ulcers or lesions. Oropharynx is clear. Sclerae are clear bilaterally.

NECK: Supple. No masses, no lymphadenopathy.

CARDIOVASCULAR: Normal S1, S2, no murmurs, gallops or rubs, 2+ pulses. Cap refill is brisk.

ABDOMEN: Soft, nontender, nondistended. No masses, no organomegaly.

RESPIRATORY: Clear to auscultation bilaterally. No increased work of breathing, good aeration bilaterally.

MUSCULOSKELETAL: No bony point tenderness. Full range of motion of large joints. No joint swelling or tenderness.

NEUROLOGIC: The patient is alert, oriented, follows commands and answers questions appropriately. No focal deficits.

PSYCHIATRIC: The patient's affect is appropriate.

HEMATOLOGIC AND LYMPHATIC: No bruising or bleeding or petechiae.

DERMATOLOGIC: The patient does have a red plaque over her upper extremities and parts of her upper chest and back, as well as a more of an evanescent rash on some of her lower extremities.

More mild facial involvement of the midface and cheeks. Rash is blanching with irregular borders. Does not appear to be tender, is not warm.

Differential

History

What's that Acromnym

PAST MEDICAL HISTORY: The patient had a skull fracture in 5th grade. No previous surgeries.

SOCIAL HISTORY: The patient is sexually active with 1 person. No history of sexually transmitted infections. Her partner does not use a condom.

Patient is from Seattle, is a freshman at U of A. No other travel outside of Washington.

MEDICATIONS: An oral contraceptive pill. Benadryl which has not been helping for her rash, as well as Advil and prednisone as above. Was previously on Adderall, but has not been taking that for the past several months. Has also been taking Excedrin.

FAMILY HISTORY: No relevant family history; dorm mate had a staph skin infection approximately 1 month ago.

REVIEW OF SYSTEMS:

CONSTITUTIONAL: The patient had lost 4 to 5 pounds over the course of this illness, but had been eating more.

ENT: Has had no runny nose or cough.

RESPIRATORY: No trouble breathing.

CARDIOVASCULAR: No history of heart disease.

GASTROINTESTINAL: Abdominal cramping in the lower part of her abdomen.

GENITOURINARY: No UTI symptoms or discharge.

MUSCULOSKELETAL: No arm or leg pain, no joint pain.

NEUROLOGIC: No history migraines. The patient's headache is described as being behind the eyes and sometimes in the back of her head, comes and goes.

HEMATOLOGIC AND LYMPHATIC: No bleeding or bruising.

PSYCHIATRIC: No symptoms or history.

ALLERGIC: The patient has no known food or medication allergies

Final Destination

serum glutamic- pyruvic transaminase

serum glutamic- oxaloacetic transaminase

Diagnosis

PMLE

Studies?

Physical Exam

Labs/Studies

Chest Radiograph:

The cardiomediastinal silhouette and pulmonary vasculature are within normal limits. There is no focal consolidation, pleural effusion or pneumothorax. The aortic arch and gastric bubble are left-sided. The visualized osseous structures are within normal limits.

Cocci Titers:

Negative

Polymorphic Light Eruption

Most common in females < 30 yr

first eruption usually occurs with prolonged sun exposure during spring/summer

Onset is delayed hours to days after sun exposure

Lasts for days to weeks

Systemic symptoms of fever, chills, headache, and nausea are rare but may accompany PMLE

Distribution is usually symmetric

Each patient is different, most commonly exposed or lightly covered skin on the face, neck, upper chest, and distal extremities.

Lesions have various morphologies

pruritic, 2- to 5-mm, grouped erythematous papules or papulovesicles

edematous plaques that are > 5 cm in diameter.

Most cases are due to UVA sensitivity, some are UVB induced

Diagnosis-clinical

Biopsy-Focal epidermal spongiosis with focal lymphocyte exocytosis and a perivascular and periadnexal lymphohistiocytic infiltrate with occasional eosinophils and rare neutrophils

Treatment

Sun avoidance/protective clothing/broad-spectrum sunscreens

Mid- to high-potency topical or systemic corticosteroids

Prophylactic narrow band-UVB or PUVA(psoralen + UVA)

Cheap version-sun bathing

Lupus

Bacteremia

JIA

Viral exanthem

STI

IBD

Dermatomyositis

Mycoplasma

Medication reaction

EBV

Cocci

Consider travelling with a potent topical corticosteroid and/or to take a short course of prednisone

She was not from Forks