Morning Report 2.19.20

Today we had an excellent outpatient case presentation by Dr. Chen. A patient presented with rash consistent with Erythema Multiforme. The rash was present on his palms.

Here are some quick take away points.

What is a quick differential and scenarios of a rash involving the palms (and soles)?

  1. Hand-foot-and-mouth disease (Coxsackie virus)
    • papulovesicular lesions, oral lesions, in children or with exposure to children
  2. Rocky Mountain Spotted Fever (Rickettsia rickettsii)
    • petechial, starting on wrist and ankles and spreading to the palms / soles / trunk
    • remember outdoor exposure and geography! (south and eastern US)
  3. Secondary Syphilis (Treponema pallidum)
    • maculopapular, also on face and trunk, if 6 months prior had painless chancre and / or has risk factors
  4. Disseminated Gonococcal infection
    • pustular or vesiculopustular, dermatitis, migratory arthritis, and tenosynovitis, and / or has risk factors
  5. Erythema Multiforme (multiple etiologies)
    • anular / targetoid lesions, pruritic

Others; Contact dermatitis, Kawasaki disease, Rubella, Scabies, Staphylococcal scalded skin syndrome, Stevens-Johnson syndrome, Toxic epidermal necrolysis, Toxic shock syndrome, HIV

What is Erythema Multiforme?

  • acute, immune mediated condition
  • round, erythematous macules which evolve into target lesions over 3-5 days, disappears in 2 weeks
  • appears symmetrically on extremities, and may involve mucosa

90% of EM is due to infections

  1. HSV (HSV-1, HSV-2)
  2. Mycoplasma pneumoniae

Others; EBV, CMV, VZV, (many other viral and bacterial causes)

10% of EM is due to drugs

  1. Sulfonamides (TMP-SMX)
  2. NSAIDs
  3. Penicillins

Others; Anticonvulsants, allopurinol, cephalosporins




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