Cough, Conjuctivitis, and Mucositis...what is the diagnosis?

7/30/2019 Cough, Conjuctivitis, and Mucositis...what is the diagnosis?

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One last quiz session…

Anna Petersen MD, PGY-3

1/11/13



• Almost 8 yr old F, previously healthy, who presented with a

crusted shut painful mouth, red left eye, and cough.

• She first started having a cough ~10 days PTA and

grandmother noted “red eyes” at this time. She went to an

Instacare and was diagnosed with viral conjunctivitis. Her

vision was normal and RSS (-).

• She took Sudafed for 4 days; her eyes stayed slightly red, and

cough continued, but she did not seem to worsen.

• Four days PTA developed 2 white sores on the inside of her

cheeks and sore throat. She also had some low grade fevers,

decreased oral intake, and less energy.



• She went to see her PCP 3 days ago, and also had a red blotchy

rash on the back of both her knees which her PCP believed was

eczema.

• Her PCP prescribed amoxicillin (?) which she felt helped a

little, but she didn't get all the way better.

• The two days before presentation, her lips and tongue started

getting really painful and crusting, despite Grandma’s attempt

at vaseline and wet soaks. They bled easily when wiping the

crust away. She also developed a red sore on her left

cheek. Her PO intake decreased to almost none. She also c/o a

painful, sore tongue.



• PMH: Eczema (?), no seasonal allergies, no asthma, no

history of skin infections or herpes

• PSH: T&A and tubes at age 4

• IMMS: up to date, flu this year already

• MEDICATIONS: Motrin, Sudafed, and Amoxicillin recently;

MVI regularly

• ALLERGIES: NKDA

• DIET: normal for age, no recent additives

• FAMILY : no family members with skin infections, MRSA, or

herpes.

• SOCIAL : Lives with parents and grandparents. New dog on

12/7/12. No sick contacts.

• DEVELOPMENTAL: Normal development



• No fever, no congestion, no pruritis with rash, no n/v/d, normal

mental status

• Decreased eating/drinking ability, (+)pain, some fatigue

• Saw her PCP on the morning of admission, who was worried

for dehydration, and she was a direct admit.



GENERAL: Pale girl awake, quiet and shy, uncomfortable, inhospital gown.

HEAD: NCAT.

EYES: PERRL, EOMI, conjugate gaze, scleral and conjunctival

injection on lateral side of left eye. Bil erythema and swellingnear lacrimal ducts with yellowish crusted discharge.

EARS: TMs clear bil, nml light reflex and landmarks.

NOSE: Nares patent, no discharge or obstruction.

MOUTH: lips crusted together with dried exudate. small straw

sized hole left open. lips brightly erythematous and edematous;

very friable. Patient unable to extend jaw or talk easily due to

not opening lips.



CV: Normal rate, rhythm, and S1/S2, no murmur, rub or gallop.Cap refill<2s.

LUNGS: CTAB, no wheezes, rales, or rhonchi. No incr WOB.

ABD: soft, non-tender, non-distended with active bowel sounds

and no masses or HSMEXT: all extremities warm and well perfused. No cyanosis,clubbing, or edema.

BACK: no abnormalities noted.

GU: normal Female external genitalia, Tanner stage 1.NEURO: awake and alert, cranial nerves II-XII grossly intact,grossly normal strength and tone, patellar tendon reflexes normal.

SKIN: Small papule on left check that is erythematous with smallcentral scab.



• “Patient's mouth is extremely dry with large dry dark red and

brown crusting. The top and bottom lip are connected by this

crusting with a pin head size hole in the crusting.

• Applied a warm wash cloth to the lips to help soften crusting.

Gently removed 80%-90% of the crusting. Lips bled slightly.

Patient's inside of the mouth is also very sore with some moist

lesions noted in the mouth however it was slightly difficult to

fully assess. Tried to clean inside of the mouth with pink mouth

swabs and cold water, but this was too painful for the patient.Applied Sween 24 to the lips. “



8 yr old female with cough, conjunctivitis, and mucositis.



Fixed drug reaction

Erythema mulitforme

SJS/TEN

Exfoliative erythroderma

Irritant Contact Dermatitis

Allergic Contact Dermatitis

Cocksackie mucositis

HSV 1, 2 (primary)

Cutaneous HSV

Ocular HSV

Eczema herpeticum

SSSS

Pemphigus Vulgaris

Bullous Pemphigoid

Mucous Membrane

PemphigoidBenign chronic bullous

dermatosis of childhood



Bullous pemphigoid

Dermatitis herpetiformis

Drug eruptions

Leukocytoclastic vasculitis

Lupus erythematosus

Pityriasis rosea

Polymorphic light eruption

Stevens-Johnson syndrome

Toxic epidermal necrolysis

Urticaria

Urticarial vasculitis

Viral exanthems



• VRP PCR

• HSV PCR or culture

• Routine culture of affected surface*

• Mycoplasma PCR



• SJS and toxic epidermal necrolysis have traditionally been considered themost severe forms of erythema multiforme (EM).

• It was proposed that EM major is distinct from SJS and TEN on the basis of

clinical criteria.

• The proposed concept is to separate an EM spectrum from an SJS/TEN

spectrum.

Grade 1: SJS mucosal erosions and epidermal

detachment <10%

Grade 2: Overlap SJS/TEN epidermal

detachment from 10% - 30%

Grade 3: TEN epidermal detachment > 30%



• Vesiculobullous disease of the skin, mouth, eyes, and genitals.The disease occurs most often in children and young adults.The cutaneous eruption is preceded by symptoms of an upper respiratory tract infection

• Initial symptoms are fever, stinging eyes, and pain withswallowing. They precede cutaneous manifestations by 1 to 3days

• Bullae occur suddenly 1 to 14 days after the prodromalsymptoms, appearing on the conjunctivae and mucousmembranes of the nares, anorectal junction, vulvovaginalregion, and urethral meatus. Ulcerative stomatitis leading to

hemorrhagic crusting is the most characteristic feature.



• Etiology:

• #1 = Drugs, Drugs, Drugs

• # 2 = Atypical infections

• Upper respiratory tract infection

• Mycoplasma pneumoniae

• GI disorders

• Herpes simplex virus

• Possible causes should be sought diligently so that recurrencescan be avoided



Allopurinol

NSAIDs

Antibiotics

Chloramphenicol

Macrolides

PenicillinQuinolones

Sulfonamides

Anticonvulsants

Carbamazepine

Lamotrigine

PhenobarbitalPhenytoin

Valproate



• Treatment• Stevens-Johnson syndrome associated with herpes simplex virus

• early use of acyclovir and prednisone

• Comfort/Supportive care

• Wound care

• Music therapy



• Habif: Clinical Dermatology, 5th ed.

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Cough, Conjuctivitis, and Mucositis...what is the diagnosis?