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Red Eyes and Red Rash with Fever: an Uncommon Initial Presentation for Staphylococcal Obturator Abscess with Adjacent Ischial Osteomyelitis

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Red Eyes and Red Rash with Fever: an Uncommon Initial Presentation for Staphylococcal Obturator Abscess with Adjacent Ischial Osteomyelitis Red eyes and red rash with fever: An uncommon initial presentation for staphylococcal obturator abscess with adjacent ischial osteomyelitis BRUCE DAVID WHITE, DO "Red eyes and red rash with demonstrates the complexities of making the fever" is a common pediatric complaint; proper diagnosis when this common triad of however, it is an uncommon initial pres- symptoms is present. entation for staphylococcal obturator ab- scess with adjacent ischial osteomyelitis. Report of case The case of a 13-year-old boy who was ad- A 13-year-old boy was brought to the pediatric mitted to the hospital with conjunctivitis, clinic of Metropolitan Nashville General Hospital, erythematous maculopapular lesions, and Sept 9, 1989, with the complaints of fever, head- ache, malaise, rash, and vomiting. Four days be- fever and had this final diagnosis is re- fore admission, he had a sore throat, low-grade fe- ported. The differential diagnosis included ver, and tiredness developed. He took no medicines various bacterial diseases, several viral ill- at that time. The symptoms persisted but he felt nesses, and rickettsial disease. well enough to go skateboarding. Two days before (Key words: Conjunctivitis, erythema- admission, his temperature rose to 105°F and he tous maculopapular lesions, fever, scarlet became anorexic and extremely fatigued. He com- fever, staphylococcal scalded skin syn- plained of pain in the back of his neck, abdomen, drome, toxic shock syndrome, measles, and left hip. On admission, he reported that he had atypical measles, Kawasaki syndrome, in- some mild discomfort when he looked at bright fectious mononucleosis, Rocky Mountain lights. He had no joint pain. Acetaminophen spotted fever, leptospirosis, ehrlichiosis, brought only mild relief of his aches and pains. Stevens-Johnson syndrome, differential di- The patient was living in a rural area. He had been in the woods often but did not recall any tick agnosis) bites, although he had numerous flea bites, prob- ably from his pet cat and dog. He did not remem- Pediatric patients commonly are seen with ber traveling outside the county, but had recently conjunctivitis, fever, and erythematous skin been swimming in a nearby creek and lake. lesions ("red eyes and red rash with fever"). The only trauma he recalled was a fall, with a In such cases, the physician must make logi- bruise to his left hip sustained when skateboar- cal, timely assessments that will lead to ding 2 days before admission. The patient thought rational treatment decisions. The differential that he had had all his childhood immunizations. diagnosis includes some life-threatening ill- He denied having any allergies. Admission vital signs were: temperature, 105°F orally; pulse, 124 nesses that, if not recognized and treated beats per minute; respiratory rate, 26 per minute; properly early in the course, have fatal conse- blood pressure, 99/44 mm Hg. quences. With such a presentation, the neces- On physical examination, the boy was well de- sity of taking a thorough history and correlat- veloped, and well-nourished but looked ill. He had ing this information with the physical findings mild photophobia. The bulbar and palpebral con- cannot be overemphasized. The following case junctivae were moderately injected bilaterally. No scleral icterus was noted. The oropharynx was From the Department of Pediatrics, Metropolitan Nash- erythematous with a red strawberry tongue. No ville (Tenn) General Hospital. Dr White is assistant pro- exudates were seen. The patient had circumoral fessor of pediatrics, Meharry Medical College, Nashville. Reprint requests to Bruce David White, DO, 194 pallor, with red, cracked, dry lips. The neck was Forestwood Dr, Nashville, TN 37209. supple, but the numerous, small anterior cervical Case report • White JAOA • Vol 91 • No 8 • August 1991 • 807 lymph nodes were tender to palpation. Brudzinskis On the third hospital day, the patient complained and Kernigs signs were negative. Heart, lung, and of severe abdominal pain. The abdomen was dif- abdominal examination yielded normal results. No fusely tender; the liver was 3 cm below the cos- red or swollen joints were observed. The left lower tovertebral margin. The hip was more painful and extremity could be moved easily with minimal the nonproductive cough, much worse. The gen- pain, but it could not be elevated past 45 degrees eralized erythematous rash began to disappear. or adducted or abducted without marked pain. Chest and abdominal roentgenograms showed no A diffuse, generalized erythematous macular abnormality. Two of the blood cultures grew or- rash was present over the trunk and proximal ex- ganisms; the first organism was identified as co- tremities. The chest and back had some small, con- agulase-positive Staphylococcus aureus. Intrave- fluent papular lesions. Pastias lines were seen in nous oxacillin, 100 mg/kg/d at 6-hour intervals, was the antecubital fossae. All the lesions blanched prescribed. Later in the day, the patient was anx- with pressure. No petechiae were seen. ious and dyspneic, the respiratory rate was 40 per Admission laboratory values were as follows: he- minute, the chest roentgenogram revealed hilar moglobin, 13.7 g/dL; white blood cell (WBC) count, streaking, and arterial blood gases were normal. 8.3 x 103/RL with 32% band forms, 60% segmented The patient was given 2 L of flow oxygen by nasal neutrophils, and 2% lymphocytes; platelet count cannula. He was transferred to Vanderbilt Chil- 205 x 103/ mm3. The urine had a high specific grav- drens Hospital for intensive care. The respiratory ity. Throat rapid streptococcal screen was negative. discomfort resolved in transit. Erythrocyte sedimentation rate was 60 mm/h. The Infectious disease and orthopedic consultations serum sodium level was 134 mmol/L, and other were obtained on arrival. Oxacillin was the only blood chemistry values were normal. The findings antibiotic therapy continued. On computed tomogra- on chest and hip x-ray films were interpreted as phy (CT) scans of the abdomen and pelvis, the area normal. around the patients left obturator foramen was ede- On admission, the patient was given intravenous matous and the internal and external obturator mus- fluids and oral acetaminophen. (Maximum tempera- cles were swollen. Hip x-ray films were unremark- ture over the next 24 hours was 102°F.) Within 12 able. These findings were interpreted as being con- hours, a presumptive diagnosis of Rocky Mountain sistent with an obturator abscess. spotted fever was made; intravenous chloramphe- The patient remained febrile but improved clini- nicol therapy was started at 50 mg/kg/d at 6-hour cally. An isotope bone scan on the fifth day showed intervals. The patient began to have a nonproduc- increased activity in the left ischial region. tive cough and chest and abdominal pain. The chest On the sixth hospital day, the patient underwent was clear to auscultation; the abdomen was dif- incision and drainage of the probable abscess. A fusely tender; and the rest of the abdominal ex- 0.25-cm cortical defect in the ischium was at the amination and rectal examination yielded normal border of the external obturator muscles origin. results. About 10 mL of gross pus welled from the lesion A second series of laboratory studies showed the under manipulative pressure. Further digital ex- following changes: WBC count, 4.7 x 10 3/4 with ploration showed an approximately 3 x 3-cm 34% band forms, 49% segmented neutrophils, and pocket just anterior to the hamstring muscles ori- 7% lymphocytes; platelet count, 147 x 103/mm3. gin on the ischial tuberosity. These lesions were The relatively low WBC count and low-normal curetted thoroughly. Intraoperative cultures were thrombocyte and serum sodium values persisted, positive for S aureus. as did the chest pain and vomiting. A second chest The patient remained febrile for the next 6 post- x-ray film showed no abnormalities. operative days on an intravenous antibiotic regi- The following morning, the patients throat was men. Periodic bactericidal titers were adequate. Af- sorer and his abdomen was more tender. The back ter the patient showed continuous, gradual improve- and buttocks were much more erythematous than ment, his therapy was changed to oral oxacillin on other areas, and a few clear vesicles were seen at postoperative day 12. He was discharged from the the patients beltline. The SMA-18 chemistry val- hospital on the 16th postoperative day on a regi- ues were normal except for serum sodium, 132 men of dicloxacillin for 4 weeks. At discharge, he mmol/dL. The WBC and platelet counts remained was walking with minimal pain, anteroposterior unchanged. One of three blood cultures grew what pelvic films were normal, and the erythrocyte appeared to be Staphylococcus. The patient contin- sedimentation rate was 69 mm/h, down from 84 ued to improve. mm/h on the day of transfer. 808 • JAOA • Vol 91 • No 8 • August 1991 Case report • White Discussion dren who received an "after-killed" virus via This case demonstrates the extremely wide dif- immunization. This patient had some of the ferential diagnosis that must be considered for symptoms of Kawasaki syndrome (circumoral the symptoms triad of red eyes and red rash pallor with strawberry tongue and red, cracked with fever. It also confirms an infrequent in- lips; rash) but lacked the diffuse lymphadeno- itial presentation of osteomyelitis. pathy necessary to the diagnosis. Epstein- The bacterial causative possibilities for Barr virus infection, the "great mimicker" of these symptoms include streptococcal and other diseases, is common in adolescents. staphylococcal disease (Table). Intense pharyn- Two infrequently seen illnesses have pre- gitis, strawberry tongue, circumoral pallor, Pas- senting symptoms seen in this case. Leptospiro- tias lines, generalized erythematous macular sis is noted for intense erythroderma and men- lesions (often "sandpapery" to touch), and a ingitis. In the case reported here, the patient left-shift with the presence of band forms sug- had been swimming in creek water, a possible gest scarlet fever.
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