Case by Kala Frye-Bourque MD, CNMC PEM Fellow

A 6-month-old female with a history of rash presents to ED with a worsening leg rash. The patient was seen by her pediatrician two days ago for a rash and “white stuff” behind her knees. Was told it was most likely a fungal infection, so the family has been applying OTC clotrimazole cream to both legs. Parents noticed the patient had a fever last night and that her rash has worsened this morning.

VS: T 37.7 C  HR 169   RR 54   97/54

General: Irritable and inconsolable
Skin: Right leg with diffuse erythema, edema, and blistering to the shin. White discharge in right knee fold. Tense on palpation.
MSK: Decreased ROM of right leg due to pain.
CV: Tachycardic, no murmurs noted. Difficult to appreciate pulses in right foot, but perfusion 3-4 seconds.
Resp: Screaming. Clear breath sounds.

Given her age, fever, and irritability you decide to draw CBC, CMP, CRP, Blood Cultures and get Urine. You have a large team of nurses and technicians who are trying to get access but are unable to after multiple attempts. In the meantime, your patient is becoming more tachycardic, and blood pressures are becoming softer but the patient continues to be active and screaming. While they continue to obtain access, you reexamine the limb and notice that there are more blisters than when she arrived.

Given her worsening exam, there is concern for necrotizing fasciitis or at least a deep space infection so you consult surgery and infectious disease. Infectious disease is also concerned for necrotizing fasciitis. Surgery fellow comes to bedside and requests a CT scan to look for air.