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Teenager with facial blisters, rash, erythema at poolside
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An adolescent female with a healthy past medical history was seen in the ED and subsequently admitted to the hospital for sudden-onset of a rash on her face. The problem was first noted the evening before, with some erythema and a stinging sensation. Earlier that day, the patient had spent most of the day playing with friends in her backyard pool. On further history, they were in the sun for much of the time without using sunscreen. When they were not in the pool, they were under a lime tree adjacent to the pool, periodically picking limes for limeade drinks. They knew of no poison ivy in the yard, and there was no animal contact.
James H. Brien
Daniel L. Green
The next day, the rash was significantly more painful and pruritic with some irregular-shaped blisters with surrounding erythema and yellowish material on her face and around her mouth (Figure 1). The patient also noticed that some of her fingers were erythematous with some blisters as well (Figure 2) along with a red streak on the right side of her neck (Figure 3). Her friend was seen by her primary provider and admitted for a similar problem earlier the same day (Figure 4). Neither patient was taking any medications prior to the onset of the problem.
Figure 1. Irregular-shaped blisters with surrounding erythema and yellowish material around the mouth.
Images: Brien JH
Figure 2. Fingers were erythematous with some blisters.
Examination on admission revealed normal vital signs and the skin findings noted above. The rest of the exam on both patients was normal for age. Lab tests were performed upon admission that included a complete blood count, complete metabolic profile and inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), which were all normal. A blood culture is pending.
Medications empirically given on admission included vancomycin, gentamicin plus Zosyn (piperacillin/tazobactam, Wyeth Pharmaceuticals), apparently due to the troubling appearance of the skin and lack of a clear explanation. A pediatric infectious disease consult was then ordered.
Figure 3. Red streak on the right side of her neck.
Figure 4. Patient’s friend admitted for a similar problem earlier the same day.
Case Discussion
The answer should be discernable with the history of lime juice exposure 24 to 36 hours earlier, along with sun and water exposure and the irregular-shaped blistering erythema of the fingers and face and mouth area to be (D) lime juice phytophotodermatitis. This cutaneous inflammatory condition occurs when the photosensitizing chemical (psoralen) in the lime gets on the skin, sensitizing it to certain wavelengths within sunlight so that upon exposure, the inflammatory reaction takes place, which may be further aggravated by contact with water. An excellent review of this condition was published by Goskowicz and colleagues from Rady Children’s Hospital in San Diego.
Figure 5. Blistering erythema.
Images: Brien JH
Treatment is symptomatic with cold compresses and topical steroids. The main goal is an accurate diagnosis by recognition of the key elements in the history. As in the case presented, these cutaneous conditions can be confusing without a thorough history; the kind of history a “medical detective” might obtain. It took questioning the patient and her mother repeatedly, with several trips back to her room, before the lime component of the history was discovered. Both patients had a complete and uncomplicated recovery.
When we were first called about the patient, we naturally thought first of sunburn, with a history of spending the day at the pool, now with blistering erythema (Figure 5). However, the pattern of the erythema did not fit with areas of normal-appearing skin that should have also been burned with the same sun exposure. Therefore, that seemed easily eliminated.
Rhus dermatitis — synonymous with poison ivy, poison oak or poison sumac — is an allergic dermatitis, caused by a sensitized person coming in contact with the chemical, urushiol, contained in the sap of the plant. The skin lesions caused by the reaction may be indistinguishable from “lime dermatitis” (Figure 6). Again, the history tells the story: You can never be sure that poison ivy is not around, but it is very unlikely in a backyard around a pool when you ask specifically about it. Treatment is essentially the same as for lime dermatitis.
Lastly, the history does not fit bullous impetigo. Adolescent girls are not likely to simultaneously and suddenly break out with bullous impetigo overnight. This is caused by a Staphylococcus aureus infection with locally contained epidermolytic-toxin production at the site of infection, producing blistering, impetiginous lesions (Figure 7). The pattern would also not likely result in the inflammation of the surrounding skin. Treatment of uncomplicated impetigo can be with soap and water, but many experts recommend a topical or oral anti-staphylococcal antimicrobial agent with these toxin-producing stains of Staphylococcus. Culture of the lesion will usually recover the Staphylococcus and provide sensitivities that can direct therapy.
As we have noted many times before, the medical history almost always has the answer to these perplexing diagnostic dilemmas; however, you may have to remove a lot of dirt to find the diamond.
I would like to thank Daniel L. Green, DO, for serving as our guest columnist this month. He grew up in Abilene, Texas, and received his undergraduate degree from the University of Mary Hardin-Baylor. He then attended my alma mater, the University of North Texas Health Science Center, Texas College of Osteopathic Medicine in Fort Worth, prior to beginning his residency training with us 2 years ago. After graduating next year, he will pursue fellowship training in emergency medicine. – James H. Brien, DO
- Reference:
- Goskowicz MO, Friedlander SF, Eichenfield LF. Pediatrics. 1994;93:828-830.
- For more information:
- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosures: Brien and Green report no relevant financial disclosures.