Triage: hand and feet rashes, headaches, fevers, for a month.
History of Present Illness: A woman in her 30’s who has had a year and a half of intermittent rash on her palms and soles including 3 times before this. Each time she gets the symptoms she has some headache but no vomiting or photophobia. In addition in the last week she has had about a week of shortness of breath and non-pleuritic non-exertional chest discomfort. She denies photophobia. focal weakness or vomiting. No other complaints.
Vital Signs: T: 37.4 °C (Oral), HR: 70, RR: 20, BP: 125/66, SpO2: 99%
Physical Exam: Normal except for rash below
Testing:
- CBC: normal
- LFT: normal
What other testing should be done today or for follow up?
- A) RPR
- B) Skin biopsy
- C) Skin allergy testing
- D) None of the above
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
- Emergency Medicine 1-Minute Consult, 5th edition
- A-to-Z EM Pharmacopoeia & Antibiotic Guide, 5th edition
- 8-in-1 Emergency Department Quick Reference, 5th edition
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QUIZ ANSWER: What other testing should be done today or for follow up?
- A) RPR – CORRECT. T pallidum antibody test was positive. RPR titer was elevated at 1:128 (took 8 days to result. This is “very high” according to ID consult)
- B) Skin biopsy
- C) Skin allergy testing
- D) None of the above
1-Minute Consult on this topic: Click HERE and go to page 148
CASE CONCLUSION: Treated with 4 weeks of doxycycline. RPR titer to be repeated in 6 months
CASE LESSONS:
- Rash on palms or soles is often something bad. Use the mnemonic MESH TREK: Meningococcus, E multiforme, Syphilis, HFMD, TEN, RMSF, Endocarditis, Kawasaki
- Other rash red flags include involvement of mucous membranes or petechiae or systemic symptoms
- The rash of secondary syphilis can reoccur for years if not treated.