Hot Seat #265: Rash Decisions
Posted on: October 25, 2026, by : Brittany Fitzpatrick
Case by Maria Elena Arrate, CNH PEM Fellow
A 12-year-old girl with hx of a thyroglossal duct cyst status post excision 1.5 months ago is presenting with 2 days of fever, headache, nausea, and a new diffuse rash. The excision was complicated by neck swelling at the surgical site despite treatment with Augmentin and subsequently underwent I&D. Follow-up with ENT demonstrated a well-healing scar, with 2 weeks of persistent yellow-clear drainage from the surgical site and associated neck swelling. CT imaging demonstrated a collection without a clear cystic wall. She was started on a two-week course of trimethoprim-sulfamethoxazole (Bactrim) which she completed 2 days ago. Patient was seen in the ED yesterday due to new onset fever and vomiting. RVP was negative and CXR was interpreted as concerning for possible viral versus other infectious process. The surgical site appeared well healed, her fever improved with antipyretics, and she was discharged home. She returns today due to persistent fever and development of a diffuse rash associated with headache and nausea. Her father additionally reported mild swelling near the midline neck scar, similar to her prior presentations that ultimately required drainage. No recent travel reported, no tick bites.
Physical Exam:
VS: 38.9°C, HR 173 (crying), RR 28, BP 111/80
General: Well appearing but irritable and difficult to examine.
Skin: Warm. Diffuse blanchable papular rash involving the neck, chest, trunk, upper extremities, lower extremities, and palms. Rash is most confluent over the chest and torso and appears pruritic. No tenderness to palpation, no sloughing, and no involvement of the groin. No purpura or vesicles. Approximately 2 cm anterior neck incision w/o surrounding erythema or drainage. Mild swelling superior to the incision. Difficult to determine tenderness due to poor cooperation.
HEENT: No mucosal lesions. Lips and tongue normal. Cerumen obstructs visualization of tympanic membranes.
Neck: Supple.
Cardiovascular: Regular rate and rhythm. Normal perfusion.
Respiratory: Clear to auscultation bilaterally. No increased work of breathing.
Abdomen: Soft, nontender, nondistended.
Musculoskeletal: Normal range of motion. No joint swelling.
Neurologic: No focal neurologic deficits.
ENT was consulted and felt the surgical site appeared reassuring with low suspicion for active infection. Ultrasound was requested to evaluate for recurrent fluid collection which showed:
Continued evolution of right submental postsurgical changes without new or enlarging fluid collection
Patient continues to be well appearing in the ED with persistent itching. No episodes of vomiting, no abd pain, no other complaints. Continues very irritable when approached. Temps range from 38-40C through the remainder of your shift despite antipyretics.
Your Spidey senses keep going back to the rash present on the child’s palms with exposure to Bactrim which is known to cause ugly drug reactions. Thankfully, dermatology was already in the ED admitting another one of your patients, so you discuss this patient’s case with them. After seeing the patient they recommend obtaining bloodwork.
Laboratory testing was obtained:
- Strep: Negative
- WBC: 3.92 K/μL
- Hb 12.9
- Plt 130
- ANC 2000
- Absolute eosinophil count: 0.12 K/μL (normal)
- Albumin: Normal
- AST: 1202 U/L
- ALT: 1884 U/L
- GGT: 192 U/L
- Total bilirubin: Normal
- Creatinine: Normal
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