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SAEM Clinical Images Series: I Cannot See My Rashes

A 37-year-old African-American transgender patient presented with progressive, bilateral painful vision loss. The symptoms began acutely in the right eye two weeks prior to presentation, eventually extending to the left eye. Symptoms were worse in the right eye and included headache, blurry vision, photophobia, and pain with eye movement. Additionally, the patient reported the appearance of a diffuse, generalized, non-pruritic, non-tender rash of unknown duration or timeline. The rash was hyperpigmented and located on the trunk, face, genitalia, palms, and soles. The patient denied any recent trauma, using eye drops, wearing glasses, recent new detergents, soaps, illness, nausea, vomiting or sick contacts.

 

rash

Vitals: HR 114; Temp 101.4 °F; BP 120/77; Resp 16; O2 98%

HEENT: Erythematous eyelids, bilateral conjunctival injection with a hazy cornea. Dilated and poorly reactive pupils, and overlying corneal edema without abrasion. Slit-lamp examination showed keratic precipitates in the anterior chamber. Visual acuity RE 20/200, LE 20/70. Intraocular Pressure (IOP) notable for OD 52, LOS 32.

Respiratory: Good bilateral air entry, clear breath sounds.

Cardiovascular: Normal rate, regular rhythm, S1,S2, no added sounds.

Skin/Extremities: Disseminated maculopapular rash all over the body, not itchy/crusty, nontender.

Neuro: At baseline mental status, AO X 3

WBC: 11.6

Hgb: 11.2

Platelets: 507

ALT: 70

AST: 80

ALK PHOS: 1449

HIV: Non-reactive

Hepatitis B: Non-reactive

Orthopoxvirus DNA: Not-detected

If emergency medicine physicians consider glaucoma due to syphilitic uveitis on their differential for patients presenting with skin and ocular symptoms, this can result in more rapid diagnosis and aggressive treatment. The CDC reported 176,713 cases of syphilis in 2021, showing an annual increase and a collective surge of 28.6% from 2020 to 2021. While the frequency of confirmed syphilis cases can vary, the global trend reveals a consistent rise in reported incidences, suggesting continued transmission of the infection. This is especially concerning because some individuals may not exhibit noticeable symptoms due to its challenging diagnosis and presentation. As a result, not all cases of syphilis are diagnosed or confirmed. Prompt recognition and treatment are crucial to save the patient’s vision and quality of life. The patient was empirically started on IOP-reducing medications, intravenous penicillin and admitted with a presumptive diagnosis of ocular syphilis. During admission, both Rapid Plasma Reagin (RPR) and trepanomal tests confirmed the syphilis diagnosis. Subsequently, the patient’s IOP normalized and vision improved to 20/200 in the right eye and 20/70 in the left.

Take-Home Points

  • High suspicion, improved awareness, increased testing, and effective surveillance systems are essential for accurately assessing the prevalence of syphilis in a given population.

  • Beginning treatment early on and before confirmatory testing in the ED will only help improve patient outcomes throughout hospitalization.

  • Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021 – Syphilis. Centers for Disease Control and Prevention. https://www.cdc.gov/std/statistics/2021/overview.htm#Syphilis. Accessed January 10, 2024.

  • Mathew D, Smit D. Clinical and laboratory characteristics of ocular syphilis andneurosyphilis among individuals with and without HIV infection. Br J Ophthalmol.2021;105:70-74.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-04-15T21:32:43-07:00Apr 21, 2025|Infectious Disease, Ophthalmology, SAEM Clinical Images|
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SAEM Clinical Images Series: Bilateral Periorbital Edema

peri-orbital edema

A 20-year-old previously healthy student-athlete female presented with a 2-week history of bilateral periorbital swelling unresponsive to steroids and anti-histamines prescribed by her PCP. The edema had been worsening, and there was a new development of throat tightening and discomfort. She denied rash, allergies, fever, URI symptoms, urinary symptoms, or new medications.

 

General: No acute distress.

HEENT: Significant bilateral periorbital edema with an otherwise normal eye exam. 2+ bilateral tonsillar swelling and erythema, no exudates. No uvula swelling or deviation. No oral mucosal lesions.

Neck: Anterior and posterior cervical lymphadenopathy.

Respiratory: No stridor.

Skin: No rash.

Abdomen: No hepato/splenomegaly. Otherwise, exam WNL.

CBC: WBC 14 with 18% Neut, 63% Lymphs, 9% Reactive lymphs

BMP: Wnl

ALT: 194

AST: 121

UA: Wnl, no protein, no blood

Urine pregnancy: Negative

Strep: Negative

Flu/Covid: Negative

*Monospot and EBV titers returned next day positive

This case presentation is an impressive example of bilateral periorbital edema as a very early sign of mononucleosis, appearing two weeks before the classic triad of fever, tonsillitis, and cervical lymphadenopathy. Peri-orbital edema has been reported in the literature to be present in 10-30% of mononucleosis cases and when present, it is often the earliest sign/symptom. Common symptoms of mononucleosis are fever, tonsillitis, lymphadenopathy, and fatigue. Less common symptoms include periorbital edema, splenic pain/rupture, rash, and neurologic syndromes.

CT image shows bulky posterior cervical lymphadenopathy. Lab studies show hematologic abnormalities, including reactive lymphocytes and mild LFT elevation, suggestive of mononucleosis. Heterophile monospot and EBV titers often are not available as STAT labs and return after the ED evaluation.

Take-Home Points

  • Bilateral peri-orbital edema can be an early sign of mononucleosis.

  • Reactive lymphocytes and mild LFT elevations can be suggestive of mononucleosis.

  • HOAGLAND RJ. Infectious mononucleosis. Am J Med. 1952 Aug;13(2):158-71. doi: 10.1016/0002-9343(52)90154-x. PMID: 12976417.

  • Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010 May 27;362(21):1993-2000. doi: 10.1056/NEJMcp1001116. Erratum in: N Engl J Med. 2010 Oct 7;363(15):1486. PMID: 20505178.

  • Aronson A and Auwaeter P. Infectious mononucleosis In: Post TW, ed. UpToDate. UpToDate; 2021.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-01-21T09:24:19-08:00Jan 27, 2025|Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: Pediatric Forehead Swelling

puffy

A 12-year-old male with a history of autism spectrum disorder and chronic sinusitis presented for forehead swelling. His mother reported that she noticed progressive forehead swelling for about one month. She had followed up with the patient’s pediatrician and ENT and was given oral cephalexin and fluticasone nasal spray which did not make any changes in his symptoms. The patient denied any fevers or headaches.

Vitals: Temp 97.4°F; BP 100/58; HR 90; RR 18; SpO2 98%.

General: Patient is comfortable appearing, in no acute distress.

ENT: 3×3 cm area of fluctuance centrally located over the forehead with no drainage or surrounding erythema that is minimally tender to palpation. No nasal drainage.

Neuro: Intact with no deficits.

WBC: 14.35

ESR: 23 mm/h

CRP: 0.74 mg/dL

CT demonstrates osteomyelitis of the frontal bone with osseous destruction with a 5 cm bifrontal complex loculated anterior epidural abscess as well as a 3 cm midline frontal subgaleal extracranial scalp abscess.

Findings are consistent with Pott’s Puffy Tumor.

Take-Home Points

  • Pott’s puffy tumor is a rare, life-threatening complication of frontal sinusitis characterized by osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp. It can be found in all age groups but is most common in adolescents.
  • MRI brain with and without contrast is the preferred imaging modality due to increased sensitivity to detect early intracranial and osseous abnormalities.
  • Treatment is typically surgical intervention with at least 6 weeks of intravenous antibiotics. The infection is typically polymicrobial warranting gram-positive, gram-negative, and anaerobic antibiotic coverage.

  • Sharma P, Sharma S, Gupta N, Kochar P, Kumar Y. Pott puffy tumor. Proc (Bayl Univ Med Cent). 2017 Apr;30(2):179-181. doi: 10.1080/08998280.2017.11929575. PMID: 28405074; PMCID: PMC5349820.
  • Masterson L, Leong P. Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009 Jun;13(2):115-7. doi: 10.1007/s10006-009-0155-7. PMID: 19352731.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-12-02T21:56:12-08:00Dec 16, 2024|Healthy in EM, HEENT, Infectious Disease, Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: An On-Target Diagnosis

erythema

A 25-year-old female with no pertinent past medical history presented to an emergency department in Massachusetts with four days of generalized malaise, myalgias, congestion, low-grade fever, and a rash behind her left knee. The patient denied cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, and diarrhea. She lives with three roommates, none of whom were sick, and she denied any other known sick contacts. She also denied any occupational exposures or recent travel, although did endorse some recent hiking in the area.

Vitals: BP 128/84; HR 88; Temp 98°F; RR 18; SpO2 (on RA) 100%

General: Well appearing

HEENT: No conjunctival injection

Cardiovascular: S1, S2; no murmurs, rubs, or gallops

Skin: Erythematous patch with central clearing in left popliteal fossa

WBC: 5.1

Hgb: 12.6

Platelets: 223

Sodium: 139

Creatinine: 0.8

ALT/AST: 22/22

COVID/Influenza/RSV: negative

This clinical image depicts erythema migrans (EM), the classic rash seen in 70- 80% of early localized Lyme disease infections. Lyme disease is a bacterial infection caused by the spirochete Borrelia burgdorferi, transmitted through bites from Ixodes scapularis (Blacklegged Tick). Lyme disease is endemic to the northeastern part of the United States but is also commonly reported in the upper Midwest region of the country. There are three stages of Lyme disease: early localized infection, early disseminated infection, and late disseminated infection. Early localized infection starts 3-30 days after a tick bite. This stage is characterized by the EM rash as well as fatigue, low-grade fevers, malaise, myalgias, and lymphadenopathy. EM develops at the site of the tick bite, although only 25% of patients with the characteristic rash recall being bitten by a tick. Over the next several days, the rash will expand and may develop a central clearing. Thus, the rash is often described as appearing like a “bull’s eye” or a “target.” Serological testing may be negative in early Lyme disease thus diagnosis at this stage is usually clinical.

Treatment for early localized infection is typically Doxycycline 100mg PO BID x 10-14 days. Cefuroxime 500mg PO BID x 14 days is another option. Amoxicillin 500mg PO TID x 14 days is the preferred antimicrobial in patients who are pregnant and/or breast-feeding. As when treating infections caused by other spirochetes such as Treponema pallidum, a Jarisch- Herxheimer reaction may occur. Left untreated, disseminated disease will develop in 60% of patients. Most symptoms will occur within days to months, although late disseminated disease may take months to years to present. A wide range of clinical presentations are possible with early disseminated disease including diffuse annular skin lesions, meningoencephalitis, cranial nerve palsies (most commonly Bell’s Palsy), peripheral neuropathies, and AV nodal blocks. Late disseminated infection can present with transient, migratory oligoarticular arthritis and non-focal nervous system symptoms such as mild encephalopathy and fatigue. Serological studies in disseminated disease are highly sensitive and the CDC recommends two-step testing such as an enzyme immunoassay or immunofluorescent antibody assay followed by a Western blot if the initial testing is positive or equivocal. Treatment of disseminated Lyme depends on the systems involved. Given the ambiguity of early serologic testing and the potential for development of disseminated disease, erythema migrans is a clinical “can’t miss” dermatologic diagnosis in the emergency department.

Take-Home Points

  • Lyme disease is caused by bites from the Blacklegged Tick and is endemic to the northeastern United States.
  • Early localized Lyme infection often presents with the erythema migrans rash, a large targetoid or bull’s eye area of erythema with central clearing at the site of the tick bite.
  • The diagnosis of early Lyme is usually clinical and the three first-line antibiotics are Doxycycline, Cefuroxime, or Amoxicillin.

  • Kowalski TJ, Tata S, Berth W, Mathiason MA, Agger WA. Antibiotic treatment duration and long-term outcomes of patients with early lyme disease from a lyme disease- hyperendemic area. Clin Infect Dis. 2010 Feb 15;50(4):512-20. doi: 10.1086/649920. PMID: 20070237.
  • Lyme Disease. Centers for Disease Control and Prevention. 2022, Jan 19. https:// www.cdc.gov/lyme/
  • Steere AC. Lyme disease. N Engl J Med. 2001;345(2):115-125. doi:10.1056/NEJM200107123450207 4. Torbahn G, Hofmann H, Rücker G, Bischoff K, Freitag MH, Dersch R, Fingerle V, Motschall E, Meerpohl JJ, Schmucker C. Efficacy and Safety of Antibiotic Therapy in Early Cutaneous Lyme Borreliosis: A Network Meta-analysis. JAMA Dermatol. 2018 Nov 1;154(11):1292-1303. doi: 10.1001/jamadermatol.2018.3186. PMID: 30285069; PMCID: PMC6248135.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-12-02T21:38:35-08:00Dec 9, 2024|Dermatology, Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: Rash and Fever in a Returned Traveler

A 21-year-old otherwise healthy female presented to the Emergency Department with a fever after recently returning from Ghana. She reported intermittent fever, headache with photophobia, diarrhea, joint pains, and generalized weakness. She also noticed a diffuse, intermittently pruritic rash on her trunk and extremities. While in Ghana, she volunteered at a refugee hospital, ate street food, and was exposed to local animals. Prior to her stay in Ghana, she spent a week in Bali. She reported receiving vaccines before leaving but was unsure which vaccines she received.

petechia

Vitals: Temp 102.9°F; HR 126; BP 114/78; RR 18; O2 sat 98% on room air

General: Uncomfortable-appearing with her eyes closed on initial exam.

HEENT: PERRL, EOMI, Normal conjunctiva without erythema; Full ROM of neck without neck stiffness/rigidity.

GI: Abdomen soft, non-tender, nondistended. No palpable masses, hepatomegaly or splenomegaly.

MSK: No evidence of joint effusion, erythema or tenderness.

Skin: Diffuse maculopapular rash to all four extremities and chest with confluent erythema noted in some areas intermixed with small areas of spread skin, scattered papules around the ankles consistent with mosquito bites.

White Blood Cell (WBC) Count: 2.78 k/mm3

Hemoglobin: 12.9 gm/dL

Hematocrit: 38 %

Platelets: 125.3/mm3

ESR: 10 mm/hr

CRP: 9.37 mg/L

AST: 42 U/L

ALT: 58 U/L

This is a case of Dengue Fever. This diagnosis should be considered in a returning traveler from an endemic region (i.e., Asia, India, Latin America, Africa) with a fever above 40°C, retro-orbital headache, myalgias, nausea, vomiting, and/or rash. The characteristic rash associated with dengue is described as “islands of white in a sea of red”, with confluent erythema and small areas of spared skin. A bedside tourniquet test can also be performed by inflating a blood pressure cuff around the upper arm for five minutes at a pressure halfway between the patient’s systolic and diastolic blood pressure. This test is deemed positive if more than 10 petechiae are present within a square inch of skin, suggesting capillary fragility.

Although mild cases of dengue can be treated supportively, more severe cases typically require hospitalization. Some warning signs of severe disease include abdominal pain or vomiting, hepatomegaly, signs of volume overload including ascites or pleural effusion, and an increase in hematocrit with rapid thrombocytopenia. Severe dengue can present with shock, volume overload, severe bleeding, encephalopathy, and liver failure. Emergency physicians must keep a broad differential when evaluating fever in return travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Take-Home Points

  • Consider Dengue Fever in patients returning from endemic regions with classic symptoms including fever, retro-orbital headache, nausea, vomiting, myalgias, and rash.
  • Gold standard diagnostic testing such as ELISA is often unavailable in resource-limited settings and even when available, this confirmatory result won’t be available in the acute care/emergency setting.
  • In patients for whom a diagnosis of Dengue Fever is suspected based on history and physical exam, the tourniquet test provides a rapid beside analysis to aid in patient diagnosis and management.

  • Schaefer TJ, Panda PK, Wolford RW. Dengue fever. StatPearls. Updated November 14, 2022. Accessed August 5, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430732/? report=reader.
  • Kenzaka T, Kumabe A. Skin rash from dengue fever. BMJ Case Rep. 2013: bcr2013201598.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-12-02T21:29:46-08:00Dec 6, 2024|Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: This Rash Came Out of No Where

crusting

A 26-year-old male with a past medical history of eczema presented to the Emergency Department with a rash for two days. The patient stated he first noticed a rash on his right arm that rapidly spread to his face, chest, and left arm. He reported having similar rashes before but never to this extent. The patient stated he was given Bactrim and amoxicillin about one month ago for another rash, though he was unsure of the diagnosis. He denied any known allergies or exposures to new foods or hygiene products. He had no chest pain, SOB, nausea, or diarrhea. He lives in a correctional facility and does not know of anyone with any rashes.

 

Vitals: Temp 102.7°F; BP 134/81; HR 137; RR 17; O2 100% on room air

Cardiac: Tachycardic, no murmurs

Lungs: CTABL

Skin: Pustular vesicles with scattered areas of confluency on face, upper extremities and torso. Yellow crusting on face, no mucosal involvement.

WBC: 17

Platelets: 261

Blood cultures: One of two positive

CMP and UA WNL

Non-bullous Impetigo

Impetigo is a rash that effects the epidermis. There are two main types, bullous and non-bullous. S. Aureus and S. Pyogenes are the most common causes of non-bullous impetigo with S. Aureus accounting for up to 80% of cases. Impetigo is highly contagious and patients often self-inoculate other areas of their skin after the initial lesion develops. As papules develop, they fill with pus and once ruptured a classically characterized honey-colored crust is left on the skin. It is more common in immunocompromised patients, diabetics, patients with poor hygiene, and those patients who spend time in crowded dwellings such as daycare or prison. Systemic antibiotics are recommended in all cases of bullous impetigo and in non-bullous impetigo if there are more than five lesions, signs of deeper tissue involvement, or systemic symptoms as was the case with this patient. Beta-lactamase-resistant antibiotics such as Keflex or Augmentin are often the first line and if the patient resides in an area with a high prevalence of MRSA, doxycycline or clindamycin are recommended. Once diagnosed, it is important to wash any clothing, bedding, or infected surfaces to prevent further household or community spread. In the case of this patient, he developed systemic symptoms ultimately becoming septic, and required admission with IV antibiotics. He made a full recovery.

Take-Home Points

  • Suspect in patients who are immunocompromised or have contact with crowded dwellings such as daycare or jail.
  • The classic skin finding is a honey-colored crust.
  • Patients with systemic symptoms or more than five lesions need systemic antibiotics.

  • Nardi NM, Schaefer TJ. Impetigo. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https:// www.ncbi.nlm.nih.gov/books/NBK430974/

  • Group A Strep Infection. (n.d.). Group a Strep Infection. https://www.cdc.gov/group-a-strep/?CDC_AAref_Val=https://www.cdc.gov/groupastrep/diseases-%2520hcp/impetigo.html

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-12-02T21:22:36-08:00Dec 3, 2024|Dermatology, Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: Below the Chin, Badness Lies Within

neck swelling

A 50-year-old male with insulin-dependent Type 2 Diabetes presented to the emergency department with three days of pain and swelling on the right side of his neck. He endorsed progression of his symptoms, reporting that he was now having fevers, myalgias, and intermittent difficulty swallowing solid foods.

 

Vitals: BP 153/96; HR 110; T 100.0°F; RR 16; O2 sat 97%

General: Appears uncomfortable

HEENT: Mild right-sided facial swelling. No trismus. No gingival inflammation or swelling or induration to suggest abscess. There is focal swelling and tenderness to palpation, without overlying erythema, throughout the right submandibular triangle, and along the sternocleidomastoid.

MSK: Limited active right shoulder range of motion secondary to pain

WBC: 10.4

Hgb: 14.4

Plts: 213

Na: 131

K: 3.7

A1C: 13

Lemierre syndrome (LS) is a rare complication of bacterial pharyngitis/tonsillitis and involves an extension of the infection into the lateral pharyngeal spaces of the neck with subsequent septic thrombophlebitis of the internal jugular vein (as seen on CT). Patients may present with trismus, dysphagia, and fever. Due to the possibility of widespread septic emboli, patients may experience sequelae of systemic infection with dyspnea, focal neurologic deficits, and abdominal pain. Treatment consists of prompt antibiosis and rapid source control.

Most cases of bacteremia in Lemierre syndrome are caused by Fusobacterium necrophorum, an anaerobic gram-negative rod that colonizes the oropharynx. This bacterium causes platelet aggregation and thrombus formation through hemagglutinin production and direct activation of the coagulation cascade. However, up to one-third of patients are found to have a polymicrobial infection with streptococcus and staphylococcus species frequently present.

Take-Home Points

  • Lemierre syndrome (LS) is a rare infection. However, the incidence of LS has been increasing in recent decades due to more judicious use of antibiotics for pharyngitis.
  • A high index of suspicion must be maintained to diagnose Lemierre syndrome, with special attention to alternative diagnoses such as Ludwig angina, retropharyngeal abscess, or meningitis.
  • A thorough investigation of associated symptoms is imperative as these may represent sequelae of septic emboli.

  • Foo EC, Tanti M, Cliffe H, Randall M. Lemierre’s syndrome. Pract Neurol. 2021 Oct;21(5):442-444. doi: 10.1136/practneurol-2021-002928. Epub 2021 May 7. PMID: 33963085.
  • Forrester LJ, Campbell BJ, Berg JN, Barrett JT. Aggregation of platelets by Fusobacterium necrophorum. J Clin Microbiol. 1985 Aug;22(2):245-9. doi: 10.1128/jcm.22.2.245-249.1985. PMID: 4031037; PMCID: PMC268368.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-06T22:10:20-07:00Sep 20, 2024|ENT, Infectious Disease, SAEM Clinical Images|
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