Diagnostic challenge

Abstract

A 4-year-old female patient with no past history of interest presented with cutaneous rash of 24 hours' duration. She had a fever of 38.5ºC, cough and rhinorrhea in the previous days. She has taken paracetamol for fever, denies other drugs. Vitals are normal. Physical examination (figure 1-2) shows generalized exanthema with erythematous dianiform lesions with violaceous center, with positive Nikolsky's sign. Erosions and ulcers together with severe involvement of ocular mucosa (with purulent conjunctivitis), oral (dry and crusty lips, jugal mucosa and tongue with multiple aphthous ulcers) and genital (vulvar). Desquamated lesions in the auricle. Initially, blood tests showed leukocytosis of 34,000 with 89.2% neutrophils and elevated acute phase reactants with CRP of 5 mg/dl. Chest X-ray with bilateral interstitial infiltrate without evidence of condensation or ectopic air. Serology, blood culture, Mantoux was performed. The patient was admitted with intravenous fluid therapy and analgesia (paracetamol and metamizole) and the dermatology department was contacted to perform a biopsy with direct immunofluorescence punch. Twenty-four hours after admission, serology was positive for Mycoplasma pneumoniae (≥ 1/128). He presented clinical and analytical worsening and difficulty in pain control, so it was decided to contact the ICU, which accepted transfer.