A 30-Year-Old With a Full-Body Rash, Vomiting, and Confusion

Andrea Bianchin, MD; Moreno Agostini, MD


September 22, 2021

Physical Examination and Workup

Upon physical examination, the patient appears drowsy and uncomfortable. Her oral temperature is 100.9°F [38.3°C]. She is tachycardic and hypotensive, with a heart rate of 120 beats/min and a blood pressure of 80/60 mm Hg. Her respiratory rate and oxygen saturation are normal (at 16 breaths/min and 99% while breathing room air, respectively). She grimaces in pain with movement of the joints—particularly with movement of her neck, which is limited. Her pupils are 3 mm and equally reactive. Her neurologic examination findings, including a cranial nerve inspection, are normal (except for her drowsy mental status).

The patient has a nonpainful purpuric rash on her arms, trunk, and face consisting of patchy macules approximately 1-4 cm in diameter (Figures 1 and 2).

Figure 1.

Figure 1.

Figure 2.

No cervical, axillary, or inguinal lymphadenopathy is noted. Her lungs are clear, and her heart sounds are normal, without any murmurs or gallops. She has a soft and nontender abdomen, with no splenomegaly. No midline spinal tenderness or costovertebral angle tenderness is detected. No evidence suggests joint involvement, and no tenderness or swelling is noted. The remainder of the examination is unremarkable.

Laboratory studies show an elevated white blood cell count of 17.6 × 103 cells/µL, a hemoglobin level of 13.6 g/dL (reference range, 12-15.5 g/dL), and a platelet count of 54 × 103 cells/µL (reference range, 15-40 × 103 cells/µL). Her creatinine level is 3.3 mg/dL (reference range, 0.74-1.35 mg/dL), and her blood urea nitrogen level is 57 mg/dL (reference range, 10-20 mg/dL). Electrolyte concentrations and hepatic studies are normal.

The patient's myoglobin and creatine kinase concentrations are elevated, at 332 µg/L and 149 U/L, respectively. The C-reactive protein level is high, at 22 mg/dL. The partial thromboplastin time is elevated at > 120 seconds, and the international normalized ratio is 2.14. The D-dimer value is markedly elevated, at > 10 µg/mL. A serum pregnancy test is negative.

Arterial blood gas analysis shows a pH of 7.3 (reference range, 7.35-7.45), a lactate level of 64.9 mg/dL (reference range, 4.5-19.8 mg/dL), a partial pressure of carbon dioxide of 35.4 mm Hg (reference range, 35-45 mm/Hg), a partial pressure of oxygen of 318 mm Hg (reference range, 75-100 mm Hg), and an oxygen saturation of 99.3% (reference range, ≥ 95%) while using an oxygen mask at 10 L/min. Blood is drawn for culture and sent to the laboratory.


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