An 83-year-old woman is seen in outpatient clinic because of a tremendously pruritic rash of 7 days’ duration. Has not changed laundry detergent or soap, nor worn new clothing without washing it. Lotion and colloidal oatmeal baths have not helped. Has mild dementia but is well able to describe current and recent symptoms.
Two weeks earlier had bronchitis. Took oral cephalosporin that was prescribed, but only for 4 days; cough and fever abated promptly, but skin began to itch. Stopped antibiotic on her own without calling in. Then rash appeared and quickly spread. Did not have antibiotic-induced diarrhea.
Has taken phenytoin and phenobarbital for a seizure disorder without incident, for many years. Serum levels are in the therapeutic range.
Uncomfortable woman who scratches her arms and shoulders frequently, then apologizes for lack of self control. Temperature, pulse, and respiration rate normal; SaO2, 94% on ambient air. Chest clear. Abdomen not distended. Mouth, nails, and eyes normal. Extensive purple ecchymoses and red raised areas on skin of legs; smaller but similar areas on arms, some with marks of excoriation. No vesicles. Breasts are spared. No herald patch or target or iris lesion is seen.
Eosinophils, 14.3% of differential white blood cell count.
What's Your Diagnosis?
1. Mosqueda L, Burnight K, Liao S. The life cycle of bruises in older adults. J Am Geriatr Soc. 2005;53:1339-1343.
2. Katta R, Anusuri V. Serum sickness-like reaction to cefuroxime: a case report and review of the literature. J Drugs Dermatol. 2007;6:747-748.
3. Williams LH, Raugi GJ, Dhaliwal G, et al. “Are we there yet?” J Hosp Med. 2007;2:181-188.
4. Akinlade BK, Schneiderman H, Gupta P. Butterfly sign of chronic pruritus. Consultant. 2002;42:903-912.
5. Auletta MJ, Headington JT. Purpura fulminans: a cutaneous manifestation of severe protein C deficiency. Arch Dermatol. 1988;124:1387-1391.
6. Karchmer AW, Ellman L. Petechiae due to drug-induced platelet dysfunction [letter]. N Engl J Med. 1976;295:451.
7. Ruffing KA, Hoppes P, Blend D, et al. Eosinophils in urine revisited. Clin Nephrol. 1994;41:163-166.
8. Patterson R, Dykewicz MS, Gonzalzles A, et al. Erythema multiforme and Stevens-Johnson syndrome: descriptive and therapeutic controversy. Chest. 1990;98:331-336.
9. Barnes SB, Dire DJ. Stevens-Johnson syndrome and the spectrum of erythema multiforme. Consultant. 1994;34:1721-1723.
10. Uwaifo GI, Schneiderman H, Daman LA. Toxic epidermal necrolysis (in this case related to terbinafine): a lethal dermatologic emergency. Consultant. 1999;39:1147-1167.
11. Cahill J, Sinclair R. Cutaneous manifestations of systemic disease. Aust Fam Physician. 2005;34:335-340.
12. Schneiderman H, Datunashvili A. Multiple age-associated dermopathies in a nonagenarian: senile comedones, solar elastosis, xanthelasmas, and perioral telangiectases. Consultant. 2003;43:1158-1164.
13. Martin JA, Finlay A. Skin disease in the elderly. Practitioner. 2006;250(1683): 6-8, 10, 12.