High grade fever with pus...

A 50-year-old, morbidly obese female with a past medical history of hypertension, hyperlipidemia, polycystic ovary syndrome, and obstructive sleep apnea on CPAP presented to the emergency department with high-grade fever (39.5°C), tachycardia (118 bpm), diarrhoea, leukocytosis (11,000/mm3) with left shift, acute renal failure, and liver dysfunction. She was prescribed amoxicillin at urgent care for suspicion of tick bite 8 days previously as she was allergic to doxycycline. 

Upon examination, she was found to have confluent erythema described as tiny pustules forming lakes of pus on her chin, cheeks, upper neck, and hairline and just below the ear, as well as diffuse hives on the back and face. There was no hemorrhagic crusting, and Nikolsky's sign was negative. The mucous membranes were spared. The genital region showed no visible ulcers. Over the next few hours, she experienced fluid-nonresponsive hypotension. She needed elective intubation due to increased work of breathing and respiratory fatigue. She also required blood pressure support with norepinephrine. With a working diagnosis of septic shock, she received intravenous fluids and antibiotics, including ceftriaxone, metronidazole, and levofloxacin. She also received intravenous bicarbonate followed by 2 sessions of hemodialysis for her acute renal failure causing severe metabolic acidosis. As part of the sepsis workup, multiple blood cultures turned out negative. Since the pustules were nonfollicular, bacterial folliculitis was less likely. A swab from the affected site showed normal skin commensals.

The patient received intravenous methylprednisolone (100 mg once daily) for 3 days with discontinuation of antibiotics. Penicillin and cephalosporin were added to the patient's allergy list to prevent a recurrence. Over the next 2 days, the patient's condition improved. Her vitals stabilized, she was extubated, and her rash began to clear with desquamation. On day 9, she was discharged home. She received triamcinolone 0.1% cream for 2 weeks post-discharge and improved.