| Introduction: |
| A 16 year old high school football player was transferred to the Johns Hopkins Children's Center for evaluation of fever for 1 month associated rash, cough, vomiting, fatigue, and weight loss.
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| History: |
| One month before his admission he developed fever, fatigue weakness, cough, vomiting, and sore throat. Although he felt somewhat better after 10 days of oral penecillin he complained of persistent fatigue and a weight loss of 20 pounds. Three days prior to admission he developed dyspnea, palpitations, tender calves and painful nodules on his ankles. Nodules were seen in his lungs on a chest X-ray from the referring hospital, and a CT scan confirmed the pulmonary nodules and also demonstrated nodules in his liver
He was on no medications and had no history of medical illnesses or surgeries. Immunizations were up to date. Before his current illness he was the star quarterback for a local high school team.
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| Clinical
Presentation: |
| On physical examination he appeared well and appropriated oriented. However, he remained in bed and refused to move his legs, because his calves and ankles were exquisitely tender. He had a temperature of 38.9 degrees C, pulse 120, respiratory rate 22, and blood pressure 128/78. His spleen was just barely palpable
He had tender purpuric nodules scattered on the soles as well as the back and sides of his ankles and the right elbow. A 1 cm nodule on the lateral aspect of the right ankle showed overlying stellate shaped necrosis.
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| Pathology: |
| Skin punch biopsies taken from the lateral aspect of the right ankle and from the back of the left ankle showed an intense infiltration of neutrophils with scattered eosinophils in the reticular dermis extending into the subcutaneous fat and nearby medium sized vessels. There was evidence of vascular destruction with fibrin deposition and necrosis of the surrounding dermis. The papillary dermis and epidermis were relatively spared of inflammation. A Gram stain shows abundant gram-positive cocci within the lumina of several vessels. |
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| Question
1: |
| What were the possible sources of the Gram positive cocci found in the skin biopsy |
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| Question
2: |
| How would you evaluate this patient? |
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| Question
3: |
| What risk factors might make this adolescent prone to serious bacterial infections? |
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