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BACKGROUND
A bedridden 85-year-old woman with advanced multi-infarct dementia is sent in from a nursing home for evaluation of a rash on her abdomen with a possible skin infection at her gastrostomy tube (G-tube) site. The nursing-home staff first noticed the rash 2 days ago. It apparently began after levofloxacin therapy was started for a urinary tract infection. Because skin creases and the umbilicus were involved, a topical antifungal was started, but no improvement was noted. The patient has no fever or rigors.
On physical examination, the patient smiles when spoken to and has good ocular tracking, but she cannot meaningfully verbalize and follows only the simplest of commands. Her vital signs are within normal limits, and she appears to be in no distress. Other than baseline right-hemiparesis, examination yields unremarkable results except for the skin findings.
Although the scalp, palms, and mucous membranes appear to be spared, the patient is noted to have a generalized, patchy, erythematous rash involving less than 5% of her body surface. The rash is present around the side of her neck and her upper abdomen, but it seems to be worst around the G-tube and in the umbilicus (see Images 1-2). The distribution seems to suggest a fungal etiology because of the predilection for moist areas. However, once the foam booties used to prevent pressure sores are removed from her feet, impressive, tense blisters on an erythematous base are noted (see Image).
What is the diagnosis? |
Hint
The nature and location of the rash is key. |
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Authors:
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D. Brady Pregerson, MD,
Attending Physician,
Department of Emergency Medicine,
Cedars Sinai Medical Center;
Author,
Quick Essentials: Emergency Medicine and Pharm Animals Pharmacopoeia (www.ERpocketbooks.com)
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eMedicine
Editor:
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Rick G. Kulkarni, MD,
Assistant Professor,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery,
Attending Physician,
Medical Director,
Department of Emergency Services,
Yale-New Haven Hospital, Conn
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