Triage: Pt complains of rt arm/rt leg pain, fever, chills x 2 days. Fell a few days ago. Has a rash on arms/legs. Took Tylenol-1 gm 2 hours ago.
History of Present Illness: A 50-ish-year-old female comes to the ED for leg and arm pain and a rash. She has a past medical history of bipolar disorder and recently restarted lamotrigine and now has 3 days of worsening rash, right arm and right leg pain along with subjective fever and chills. She has not been able to walk due to pain in her lower leg and her forearm, both on the right. Her rash, which is mostly on the right side, she attributes to mosquito bites as her friend also has a similar rash starting after they both got bitten.
Vital Signs: Vital signs are normal.
Physical Exam: Here is what the rash looks like. She has a mild right knee effusion but no wrist effusion
Testing: mild leukocytosis with left shift, mild hyponatremia of 134, hypokalemia of 3.6, elevated ALT at 45 along with elevated inflammatory markers with ESR 58 and CRP 35.7. Lactic acid WNL. Urine positive for amphetamine, opiate and THC. X-ray of right wrist/forearm was unremarkable. Right knee X-ray showed a joint effusion but no fracture.
What is the most likely cause of the rash?
- A) Dengue from mosquitoes
- B) DGI from genitalia
- C) MRSA from scratching
- D) DRESS from lamotrigine
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QUIZ ANSWER: What is the most likely cause of the rash?
- A) Dengue from mosquitoes
- B) DGI from genitalia – CORRECT – knee aspiration showed 40,000 WBC, mostly polys and her vaginal swab was positive for GC
- C) MRSA from scratching
- D) DRESS from lamotrigine
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