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Continuation of the Summer Series
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An 11-year-old male was admitted to the hospital last month for evaluation and treatment of severe facial swelling. The history of the chief complaint was that swelling of the face with pain and itching was noticed 48 hours earlier, when he awoke with the problem. His parents had been giving him Benadryl and applying some over-the-counter cream for symptomatic relief, but these were not helping, and the swelling seemed to be worsening in degree and distribution. There was also some blistering, which was concerning for a staphylococcal infection by the referring physician, even though there has been no fever with this problem.
His past medical history is unremarkable except for an undocumented history of previous staphylococcal infections and multiple episodes of poison ivy contact dermatitis in past years. On further review of old records, he had a positive culture from a poison ivy lesion a year earlier that grew coagulase-negative Staphylococcus.
He is otherwise healthy with up to date immunizations.
He has no known drug allergies and the only medication being taken is Benadryl and the topical cream noted above.
Pediatric Infectious Disease, Scott and White's Children's Health
Center and Associate Professor of Pediatrics,
Texas A&M University,
College of Medicine, Temple, Texas.
e-mail:jhbrien@aol.com
His family history is unremarkable and no one else at home is sick or has a similar rash. However, he had been out hiking with his grandparents in some nearby woods the day before waking up with the rash, and they may have seen some poison ivy along the way.
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There was dramatic swelling of the
patient’s face, with the inability to open his right eye, and with
multiple areas of weeping lesions with some intact vesicles, predominantly on
both sides of his face, both ears and anterior and posterior neck. All
photos courtesy of James H. Brien |
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Examination on arrival to the hospital revealed normal vital signs. His only positive finding was the dramatic swelling of his face, with the inability to open his right eye, and with multiple areas of weeping lesions with some intact vesicles, predominantly on both sides of his face, both ears and anterior and posterior neck (Figures 1 – 3). There were a few patches of mild erythema at other more distant sites, including the groin. The rest of his examination was otherwise completely normal.
Lab tests done included a normal complete blood count, a negative Gram stain from one of the weeping lesions and cultures of blood and lesion are pending. The admission team began treatment with IV Ceftriaxone and Clindamycin.
What’s your diagnosis?
- Facial cellulitis
- Sunburn
- Cutaneous herpes simplex
- Contact dermatitis due to poison ivy
Case Discussion
In spite of the severity and suggestion that he may have had a staphylococcal infection, this turned out to be a severe case of otherwise uncomplicated contact dermatitis due to poison ivy exposure (D). I don’t recall a summer when we did not admit at least one patient, usually boys, for poison ivy of the face. This results when susceptible individuals come in contact with urushiol, which is the oily chemical in the sap produced by Toxicodendron radicans, sometimes referred to as Rhus toxicodendron, but usually referred to as poison ivy. This can happen by direct contact with the plant or by contact with and animal (like your dog or cat) or an inanimate object that has the oil on its surface.
These ubiquitous plants have a distinctive appearance, with their three-leaf configuration as shown in figure 4, and tend to be bright green, sometimes with a shiny surface and with the middle leaf having a slightly longer stem. They typically are camouflaged by other brush, as shown in figure 5 (poison ivy within the square). Therefore, it’s easy to see how one comes in contact without knowing it, while doing routine gardening work, hiking or other outdoor activity. The rash will usually be on the extremities, as shown in figure 6, with the characteristic linear and / or patchy raised erythematous rash. But when children get in touch with the plant, they will frequently spread it to their face. Usually girls will have less severe spread (Figure 7) than boys, as shown in the case presented. Boys are also more likely to spread the rash to the groin, especially those who grow up to be baseball pitchers (sorry, no pictures).
Prevention by avoidance is best, but when contact occurs, one can try to remove the oil with rubbing alcohol and then rinsing with water. If the rash occurs, usually a topical steroid cream will speed the resolution (Figures 8 & 9 – the same patient in figure 6). Occasionally, systemic steroids are used, as in the case presented. We usually start with 2 mg/kg/day of either oral prednisone or equivalent IV dose of methylprednisolone for about five days. You can either stop then or taper the dose over a week. Some find the application of topical Domeboro astringent solution to be helpful.
Cellulitis is always a consideration and is sometimes the driving factor in admitting these children with facial poison ivy. The same patient with severe contact dermatitis on the arm or leg would probably be treated at home with oral steroids. But there’s something about involving the face that makes us want to be more aggressive. Most of the patients we have had admitted over the years arrive already on antibiotics. However, it’s fairly uncommon for contact dermatitis to get secondarily infected (I have never seen it). Cellulitis will always have some spreading erythema that may also have some blistering similar to that seen with poison ivy.
The patient in figure 10 was admitted with the diagnosis of facial cellulitis and was taken off the antibiotics upon arrival to the ward and treated with steroids as noted above with near complete resolution in a matter of days (Figure 11).
Sunburn will certainly cause erythema and swelling of the face, but simple history of sun exposure and appearance of sun-protected areas with more diffuse redness will usually make it easy to differentiate. Beware, however, some may have poison ivy AND sunburn. Such was the case presented.
Lastly, cutaneous herpes simplex virus infections of the face are common and are usually limited to a single patch or area, with vesicular lesions (Figure 12).
Columnist comments
I would like to thank my wife, Ellen, for letting me photograph the poison ivy in her garden before she condemned it to oblivion after getting it on her arm (again) (Figures 6, 8 and 9) while doing some yard work. Since I can’t seem to keep her out of the bushes, we keep a supply of Triamcinolone cream and a Medrol Dose Pack handy, just in case. (Hopefully I can get this issue out of the mailbox before she does).
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A topical steroid cream will speed the
resolution (figure 8: before, Figure 9: after). |
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I want to thank those of you who have responded to Dr. Burnett’s book drive for some of the Afghanistan clinics. It is a decent, humanitarian thing to do, the sort of thing that wins the hearts of the people, in this case the Afghan physicians trying to cope with a very difficult situation. Please refer to the last two issues for the APO addresses.
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A patient admitted for cellulitis was treated
with steroids (figure 10: before, Figure 11: after). |
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Speaking of books, the handiest pocket book I have ever used is Nelson’s Pocket Book of Pediatric Antimicrobial Therapy by John D. Nelson, MD. The oldest copy I can find in my office is the 4th edition (1981-1982, and signed by John Nelson). Well, now this venerable pocket reference is in its 17th edition (2009) and is edited by John S. Bradley and John D. Nelson, and is published and sold by the American Academy of Pediatrics for $19.95 for AAP members or $24.95 for nonmembers (a bargain at twice the price).
You can find it by going to the AAP web site (www.AAP.org) and follow the publications tab. I still carry this book in my white coat pocket in the hospital, and use it every day. You would think I would know everything in it by now, but alas I don’t, and never will. Its well-worn exterior is testimony to that fact.
Lastly, start making plans to attend the 44th Annual Uniformed Services Pediatric Seminar (USPS) in San Diego, March 7 – 10, 2010. There’s probably not much posted yet, but you can find out more about it at the following site - http://www.aap.org/sections/uniformedservices/usps.htm. I’ll hope to see you there.