Case by Maria Elena Arrate MD, CNH PEM Fellow

A 15-year-old female presents to the ED for fever and umbilical drainage. Seen 9 days ago for drainage from the belly button that had been ongoing for 6 weeks, and intermittent fevers. Had been on a 10-day course of Cefalexin for soft tissue infection around belly button, which helped symptoms resolve; however, drainage reoccurred 1 week prior to initial ED presentation. At the time, US abdomen showed “draining sinus tract from the bellybutton to the abdominal wall” with no fluid collection, connection to bowel, or appreciable hernia.  CBC and CMP were normal.  Discharged home on Bactrim for umbilical drainage and seen by surgery outpatient with plan for CT abdomen in the future. Now returns for improved but persistent drainage from the umbilicus with associated fevers, rhinorrhea, decreased PO, and constipation. Otherwise, no PMHx or PSHx, no previous hospitalizations, takes no additional medications, and has no allergies.

T 36.6C, HR 77, RR, 19, BP 120/86, SpO2 98% RA, Weight 110.8

General:  Alert.
Skin:  Warm.  dry.  Trace dried blood present within the umbilicus.  No surrounding erythema, swelling, warmth or purulent drainage noted.  
Head:  Normocephalic.  atraumatic. Eye:  EOMI, normal conjunctiva
ENT:  Oral mucosa moist
Cardiovascular:  Regular rate and rhythm.  No murmur.  Normal peripheral perfusion.  
Respiratory:  Lungs are clear  non-labored.  breath sounds are equal.
Gastrointestinal:  Soft.  Mild diffuse tenderness.  
Musculoskeletal:   no tenderness.  no swelling.  
Neurological:  Alert.  No focal neurological deficit observed.   developmentally normal.  
Psychiatric:  Cooperative.  appropriate mood & affect.  

CT abdomen obtained and found a small fat-containing umbilical hernia with mild periumbilical skin thickening and no fluid collection. CBC, CMP, UA, Flu/COVID/RSV negative. Surgery cleared for outpatient follow-up on PO antibiotics. Given Zofran for nausea and sent home to continue Bactrim course.

The following day, the patient returns for persistence of fevers and a new rash that appeared that morning with swelling of the face, hands, and feet, and generalized pain, which the mother attributed to Zofran given the night before (8-10 hours prior to rash development).

T 39.4C, HR 107,   BP 124/56,   RR 25, SpO2 99% RA, Weight 113 kg

General:  Alert.  Obese female
Skin:  Warm. Diffuse maculopapular rash over the face, torso, and extremities. Blanchable. Confluent over face and neck. More scarce on the arms, legs and torso. Non-pruritic, non-tender.  Petechia over the flexor surfaces of the forearms. Minimal edema of hands and feet
Head:  Facial swelling
Eye:  Normal conjunctiva.  No discharge
Gastrointestinal:  Soft.  Non-distended, non-tender. Dried brown material at umbilicus without active drainage. No periumbilical erythema or discrete tenderness.
ENT:  Moist mucous membranes.
Cardiovascular: Tachycardic.  Cap refill <2sec. Pulses intact. No murmur.  No gallop. 

Blood and urine studies were ordered, which were unremarkable. 1-2 hours later, patient’s BP drops to 95/40, and the patient continues to be febrile despite antipyretics. Physical exam unchanged. Given NS bolus with improvement in BP to 106/47. WBC count normal, electrolytes normal, UA negative. Given a second NS bolus due to persistent tachycardia and started on broad-spectrum antibiotics and pressors in the setting of shock.