Bullous Impetigo

A previously healthy 3-year-old female presents with a rash consisting of numerous vesicles and open lesions.

A 10-year old male complained to his mother about right shoulder pain. When she looked at the shoulder, she noticed what she described as some “areas of blistering,” with a few that appeared to have opened, leaving some redundant skin. She took him to an urgent care clinic, where he was diagnosed with a skin infection (presumably Staphylococcus aureus) and prescribed trimethoprim/sulfamethoxazole (TMP/SMX). The lesions seemed to quickly improve, but when asked, he still complained about some pain, so she took him to his primary care clinic. The mother relayed to the triage person that the child had an episode of severe Salmonella osteomyelitis in his right shoulder when he was an infant, almost 10 years earlier. With that information, the child was sent directly to radiology for plain radiographs of the right shoulder (Figure 1), which were preliminarily read as a fracture at the old infection site. With that report, the patient was urgently sent to the local orthopedic clinic without being examined.

A 1-year-old boy presents with a diffuse rash on the body for the past 3 days (Figures 1 and 2). The rash started on his hands, then progressed to include his face, trunk, buttocks, groin, legs and feet. He also developed low-grade fevers and increased fussiness. He has a history of atopic dermatitis that has been difficult to control with hydrocortisone 2.5% ointment. He attends a day care center three times a week.