Skin & Subcutaneous Tissue


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P10_F1.jpg"}},{"insert":"\n\n"},{"insert":"It\u0027s your third week working in South Africa, and although the mosquitoes are killing you, you\u0027re enjoying the new experience.\r\n\r\nAfter finishing a delicious bowl of porridge in the hospital\u0027s cafeteria, you walk to the pediatric clinic, ready to start seeing your first patients of the day.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P10_F2.jpg"}},{"insert":"\n\n"},{"insert":"Your first patient is Josh, an 11-year-old boy with fever and joint pain. He is accompanied by his father, Mr. Jansen.\n"}]}


{"ops":[{"insert":"Josh developed an intermittent high fever around 5 days ago. After 2 days of fever, Mr. Jansen took him to a general practitioner nearby, who diagnosed a viral fever.\r\n\r\nMr. Jansen\u00a0was asked to keep Josh well-hydrated, and to give him paracetamol (acetaminophen) during the episodes of fever.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P10_F4.jpg"}},{"insert":"\n\n"},{"insert":"However, Josh developed bilateral knee and wrist pain yesterday, and his fever continued to persist. Because of this, Mr. Jansen decided to bring his son to your rural hospital today.\r\n\r\nJosh describes the joint pain as 6 on the 10-point pain scale and states that it is constant and throbbing and that his ankles have started to hurt as well.\n\nYou ask several follow-up questions and find out that Josh had a sore throat and cough 3 weeks ago, which resolved spontaneously.\r\n\r\nHis medical history is significant for generalized itchiness and urticaria following a dose of amoxicillin at age 4 and an episode of pneumonia at age 9. Both were managed on an outpatient basis.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P10_F5.jpg"}},{"insert":"\n\n"},{"insert":"Josh\u0027s vitals are as follows: heart rate 130 bpm, respiratory rate 21 cycles per minute, blood pressure 110\/70 mmHg, oral temperature 39\u00b0C (102.2\u00b0F), and oxygen saturation 97% on ambient air.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P10_F6.jpg"}},{"insert":"\n\n"},{"insert":"You note mild swelling, erythema, warmth, and decreased active and passive movements of the bilateral wrists and knee joints. Examination of the ankle joints shows passive movements to be painful.\r\n\r\nExamination of the cardiovascular system shows a regular dual rhythm, with no murmurs. The respiratory and abdominal examinations are both normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P10_F7.jpg"}},{"insert":"\n\n"},{"insert":"However, what really catches your attention is the presence of a rash over the trunk and extensor surfaces of the proximal extremities. These are erythematous, serpiginous, dark, ring-like, macular lesions with pale centers. Josh tells you that the rash is not itchy.\n\nYou\u0027ve never seen this rash in clinical practice before, but through your textbook knowledge know exactly what it is.\n"}]}