Fever, Rash, and Lung Crackles in a 25-Year-Old Woman

Jansen Tiongson, MD; John Sakles, MD; Harvey W. Meislin, MD


August 13, 2020

Physical Examination and Work-up

Upon physical examination, the patient is alert and has a normal mental status, but is otherwise pale and ill-appearing. Her blood pressure is 65/35 mm Hg, with a regular heart rate ranging between 110-120 beats/min. Her respirations are 20 breaths/min, her oral temperature is 103.46°F (39.7°C), and her oxygen saturation is 93% on room air. Her skin has a diffuse, erythematous, blanching rash; however, the integument is otherwise warm and dry to the touch. The oropharynx is clear, with no exudates or erythema.

Diffuse mild crackles are heard in the patient's lungs. Heart sounds are normal, with a regular rhythm, and her capillary refill is increased. Her abdomen is soft and minimally tender to deep palpation in the LLQ. No abdominal masses or hepatosplenomegaly are appreciated. Pelvic examination reveals no vaginal or cervical lesions, cervical motion tenderness, adnexal masses, or tenderness. No foreign bodies are visualized (Figure 1).

A complete blood count and comprehensive metabolic panel show abnormalities in the white blood cell (WBC) count of 31.6 × 103 cells/µL, band neutrophils of 13%, and a creatinine level of 2.4 mg/dL. Arterial blood gas analysis shows a pCO2 of 27 mm Hg, a pO2 of 56 mm Hg, a bicarbonate level of 19 mEq/L, and a base deficit of 4.4 mmol/L (normal range, 0-2 mmol/L). Urinalysis, cervical Gram stain, and potassium hydroxide wet preparation are all normal. Chest radiography shows changes consistent with acute respiratory distress syndrome (ARDS) (Figure 2).

After testing, the patient remains hypotensive, tachycardic, tachypneic, and febrile despite the administration of acetaminophen. A rapid-sequence intubation is performed for impending respiratory failure. She is in septic shock (etiology unknown) and is treated empirically with clindamycin, vancomycin, and meropenem. Blood, urine, and respiratory cultures are obtained, and antistreptolysin O (ASO) and toxic shock syndrome toxin 1 (TSST-1) antibody titers are ordered. Lumbar puncture is deferred, and the patient is admitted to the medical intensive care unit.


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