Case #8 -- A 13-Year-Old With a Facial Rash, Fever, and Recurrent Infections

R Avila-Connelly, MD; B Estrada, MD


January 21, 2004


A 13-year-old black girl presented with a 1-year history of hyperpigmented discoloration of the skin under her eyes. Two months prior to hospital admission, she developed erythema on the tips of her fingers and toes. Swelling of her lips and under her eyes was noted 2 weeks prior to the evaluation. The patient also noted mild gingival bleeding after brushing her teeth. Her father reported that she had a 5-day history of subjective fever. Review of systems was negative for joint swelling, weight loss, diarrhea, vomiting, or difficulty breathing. The past medical history was unremarkable.

Vital Signs: Oral temperature 101° F, pulse 111, respiratory rate 20/min, blood pressure 108/65 mm Hg, weight 64.8 kg, height 170 cm, peripheral oxygen saturation/room air 98%

The patient was alert, cooperative, and in no acute distress.

HEENT: There was significant swelling of the lips, with erythema and ulceration of buccal mucosa (Figure 1).

Hyperpigmented skin under both eyes was also noted (Figure 2).

Oral mucosa was pink and moist, with gingival hypertrophy and minor active gingival bleeding noted. Cervical lymphadenopathy (1.5-2.0 cm) was observed in the posterior cervical chain bilaterally.

Cardiovascular: Regular rate and rhythm, 2/6 systolic murmur without rubs or gallops. Chest was clear to auscultation

Abdomen: Bowel sounds present; liver palpable 2.5 cm below right costal border; spleen palpable approximately 2 cm below left costal border

Extremities: No edema; multiple small areas of subcutaneous hemorrhage on tips of fingers and toes were seen (Figures 3 and 4).


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