Benjamin D. Havemann, MD; Richard Goodgame, MDSeries Editor: Richard Goodgame, MD

Disclosures

October 13, 2005

Case Presentation

A 27-year-old woman presented with a 2-week history of diarrhea, fever, and pustular skin rash. She had a prior diagnosis of ulcerative colitis (UC), but was on no medication for over a year. Four months ago, she had a normal delivery of her third child. She was doing well until 2 weeks prior to this presentation when she developed abrupt watery diarrhea, multiple times daily. She attributed the diarrhea to a buffet meal because her sister had had 2 days of diarrhea starting at the same time. The patient continued to have 3-6 watery stools per day with intermittent bloody diarrhea. Seven days ago she presented to the emergency department (ED) with breast pain and redness. She was diagnosed with mastitis and treated with clarithromycin. Five days ago she developed painful swelling and erythema over the dorsum of her left foot. She had noted subjective fevers, chills, and diffuse arthralgias and myalgias. She went to the ED and was admitted.

The patient was diagnosed with foot cellulitis and started on clindamycin. The foot lesion worsened over a period of 2 days and surgeons were consulted. The surgeons diagnosed possible necrotizing fasciitis and took the patient to the operating room for debridement. Antibiotic coverage was expanded with vancomycin and cefepime. Infectious disease and dermatology services were consulted. She continued to have fevers and loose, watery stools, 3-4 times per day. The gastroenterology service was consulted on the fourth hospital day.

Past medical history: The patient's recent pregnancy was uncomplicated. She was breastfeeding. She was diagnosed with UC as a teenager when she presented with bloody diarrhea; she underwent endoscopy at that time. She was treated intermittently with sulfasalazine, with resolution of symptoms. She had long asymptomatic periods on no therapy. The patient experienced a relapse of presumed UC and underwent a second endoscopy while living in Russia 10 years ago. She has been off all medication for 1.5 years, with no complaints. She has had no recent travel. Her family history was negative.

Physical examination: On the fourth hospital day, results of physical exam showed a temperature of 103.4º F; pulse rate of 132 bpm; respirations of 18 breaths per minute; and blood pressure of 97/63 mmHg. She was mildly obese. The examination was normal except for the skin, lower lip, and left foot. Her left foot was bandaged due to extensive debridement (Figure 1). Her left knee had multiple small pustular lesions (Figure 2). Her right knee was similarly involved (Figure 3). There were multiple small pustules below the right breast (Figure 4). There was a superficial ulceration of the lower lip (Figure 5).

Laboratory studies: Results of routine laboratory studies showed a hemoglobin level of 11.4 g/dL; a white blood cell count of 4.8 x 103 cells/mm3; normal differential; platelet count of 244 x 103/mm3; and normal serum chemistries.

What is the etiology of the pustular skin lesions?

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What other diagnostic studies are indicated?

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