Dermatology

One evening on call, I saw a 17 year old girl complaining of oropharyngeal swelling. Ten days prior to admission, she had a cough and a wheeze. After several days, she decided to go to an emergency room where she was prescribed azithromycin for presumed walking pneumonia. Three days prior to admission at UCSF, she began complaining about mouth pain and swelling. She returned to the emergency department where they gave her some benadryl for a presumed drug reaction. Her symptoms persisted and on the day she was sent to UCSF, she developed a rash on her thighs.

When I saw her, she was complaining mostly about mouth pain. Her tongue and lips were markedly swollen, she had erosions on her buccal mucosa, and she could barely talk or swallow. Her thighs had erythematous macules, 5-15mm with a few vesicles. Over the next few hours and next few days, she developed more lesions on her trunk and extremities, and they progressed to vesicles and bullae, and finally the pathognomonic target lesion with macular erythema around a vesicular or purpuric core. Indeed, this was Stevens Johnson Syndrome, one of the few dermatologic emergencies. In this disease, the epidermis sloughs off and it can involve large body surfaces. Patients often need to be treated like burn patients since they lose so much water through evaporation and cannot control their temperatures. Stevens Johnson Syndrome (and Toxic Epidermal Necrolysis) also involve the mucous membranes; our patient had mouth and eye involvement. While Stevens Johnson Syndrome is often associated with medications, in children, it can also happen following a mycoplasma infection. Mycoplasma is a common organism in walking pneumonia. To test it, infectious disease drew some blood at the bedside, put the tube in some ice water and watched it coagulate. This was a cold agglutinin test, often positive in mycoplasma, and it was fun to do it right there to confirm our suspicion. The care was supportive and after a week and a half in the hospital, she went home.