A 39-Year-Old Woman With Past Cocaine Use, Rash, and Seizure

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 39-year-old black woman presents to the emergency department with a rash and fever. She has reportedly been ill for about a week, and her fever had reached 103°F (39.4°C). The rash is near her ear. Over the past 2 days, she has noted intermittent facial twitches and tongue extrusions (an example is shown in Figure 1), and attributes that to feeling nervous about her recent illness.

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Figure 1.

The patient has a history of mild hypertension. She admits to occasional marijuana and cocaine use 20 years ago, with no use of any drugs over recent months. Her alcohol use was sporadic over the past 10 years, with limited use (three glasses of wine per week) over the past 6 months. The patient's medications include hydrochlorothiazide for hypertension.

The patient has a remote history of depression, for which she had been given duloxetine and citalopram. She has been pregnant four times, with two spontaneous abortions for unknown reasons and two pregnancies carried to delivery, producing two healthy children now in their late teens. The pregnancies that were carried to term were uneventful except for severe morning sickness, for which she was given metoclopramide. She has no known allergies or family history of relevant diseases. The patient works as a federal government clerk.

Physical Examination and Workup

Physical examination reveals a blood pressure of 150/100 mm Hg. Her pulse is 100 beats/min. Her temperature is 101.9°F (38.8°C). Her respiration rate is 12 breaths/min. She appears well-developed and well-nourished.

Her skin has bilateral, postauricular scaly patches. She has distal streaks of red macules on her anterior legs. Examination of her head, eyes, ears, nose, and throat revealed mild pharyngeal erythema and small, scattered oral ulcers. She has slight cervical adenopathy in her neck.

Scattered bibasilar rales are noted upon chest examination. She has normal S₁ and S₂ sounds, with I/VI systolic murmur at base. Her abdomen is nontender, with no organomegaly observed. A trace of edema is noted on her ankle.

Upon neurological examination, the patient is oriented x 3. Her central nervous findings are normal. She has mild stocking-glove sensory changes. Her muscle power is 5/5. No dysmetria or ataxia is noted. She has orofacial dyskinesia with lip smacking and grimacing, as well as tic-like nodding. No chorea is noted. While in the emergency department, the patient had a 2-minute generalized seizure that began with rhythmic jerking of the right arm. Tongue biting and incontinence were noted after the event. The patient was confused for 5 minutes thereafter but then fully recovered alertness and cognition.

Six-channel serum multiple analysis findings are normal. Complete blood cell count is normal, except for mild leukocytosis (10,000 white blood cells [WBC]/µL, with minimal left shift). Her erythrocyte sedimentation rate is 50 mm/hr. No alcohol is found in her system. Total creatinine test results and thyroid panel results are normal. Noncontrast head CT scan findings are normal. Urinalysis reveals WBCs that are too numerous to count, few red cell casts, and a protein level of 30 mg/dL.

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