Initial Presentation and History
A 21-year-old gravida 3 para 1111 African-American female returned to a community hospital emergency department one week postdischarge after having been hospitalized for five days with the working diagnosis of toxic shock syndrome, but she never fulfilled the criteria of multisystem involvement. At the time of initial presentation, she was four weeks postpartum, having experienced a normal vaginal delivery without complications. She presented with complaints of a one-week history of nausea, persistent fever, and a generalized painfiil, pruritic rash. Subsequently, the rash spread to her neck, arms, hands, abdomen, back, buttocks, and thighs.
During this admission, the patient presented with a reoccurrence of her previous complaints of persistent fever and the same painful, pruritic rash which had not resolved since the first admission. She denied sore throat, cough, shortness of breath, chest pain, vomiting, diarrhea, constipation, dysuria, vaginal discharge, a history of sexually transmitted diseases, or recent sexual activity. She also denied recent travel, insect bites, sick contacts, or allergies. canadian cialis
The examination on admission revealed a thin female in no acute distress. She had a temperature of 101.9°F, blood pressure of 97/55 mmHg, pulse of 142 bpm, respiratory rate of 22, and pulse oximetry of 99% on room air. Her skin had a maculopapular rash with confluent pustular lesions located on her eyelids, neck chest, axillae, arms, back, thighs, and buttocks. The rash was erythematous, warm, and more prominent in the intertrigenous areas. She had tender lymphadenopathy involving the cervical, axillary, and inguinal areas. There was no conjunctival injection or oropharyngeal erythema. The cardiovascular examination revealed tachycardia with normal heart sounds. Lungs were clear to auscultation bilaterally. The abdomen was flat with striae, normal bowel sounds, nontender to palpation and without hepatosplenomegaly. The extremities were without swelling and there was no rash or erythema on the palmar or plantar surfaces. A pelvic exam, which was unremarkable, was performed during the first admission.