The patient is a 40-year-old male with no past medical history who presents with concerns of a rash on his hands. He states that the lesions appeared two days ago, but had a fever, muscle aches, and pruritis two days before that. He does not have a history of hives or contact dermatitis. He does not take any medications, but states he recently developed “cold sores.” His temperature is 100.6^oF, but his other vitals are within normal limits. The cutaneous rash is demonstrated below. When looking in his mouth, blistering lesions are also present. What the diagnosis and management?

Answer: Erythema Multiforme

• Erythema multiforme is the result of a T-cell mediated hypersensitivity reaction resulting in a characteristic pruritic, targetoid papules, with a hazy-center, and surrounding erythematous rings.
• 90% of cases are associated with infectious etiologies, with HSV-1 being most common in adults and Mycoplasma pneumonia in children.
  • Remaining 10% are due to drugs (NSAIDs, antiepileptics, antibiotics), malignancy, and autoimmune diseases. Their mechanism of rash formation is unknown.
• There are two specific subtypes:
  • Erythema multiforme minor: rash without mucosal involvement or constitutional symptoms
  • Erythema multiforme major: rash with mucous membrane involvement and constitutional symptoms (fever, malaise, myalgias etc.)
• Diagnosis is often clinical, but immunofluorescence can be helpful if uncertain.
  • PCR testing for both HSV and Mycoplasma pneumoniae should be done if suspected.
• Treatment is mostly symptomatic, and the rash is usually self-limited.
  • Antihistamines are useful for pruritis.
  • Systemic steroids maybe be used, but the impact on long-term outcomes and symptom duration is unclear.
  • Acyclovir may be used to prevent recurrent HSV infections.
  • Macrolides may be used in Mycoplasma pneumoniae is suspected.

References:

1. Baluzy Matthew, Karaze Tallib. Maculopapular Rashes. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recvFPlc0BmXxYuzp/Maculopapular-Rashes#h.til8vwjxmfh6. Updated June 21, 2023. Accessed January 24, 2024.
2. Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol. 2012;51(8):889-902. doi:10.1111/j.1365-4632.2011.05348.x
3. Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019;100(2):82-88.
4. J. Brady W, Pandit A, R. Sochor M. Generalized Skin Disorders. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. Accessed January 24, 2024. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221180403
5. DermNet. https://dermnetnz.org/topics/erythema-multiforme-images

A 24 year old female with a history of gallstones presents to the ED with 2 hours of severe, aching right upper quadrant abdominal pain that woke her from sleep associated with nausea and vomiting. Patient has had similar episodes of pain in the past, often after eating fatty foods. On exam, she is tender in RUQ of the abdomen and is actively vomiting. A right upper quadrant abdominal ultrasound is performed and shown below. What’s the diagnosis?

Answer: Symptomatic Cholelithiasis

• Characterized by episodes of RUQ pain that are brought on by obstructing gallstone and relieved when gallstone moves from that position
• Can progress to cholecystitis if gallstone remains in obstructing position and gallbladder subsequently becomes inflamed or infected.
• Differential: cholecystitis, choledocholithiasis, cholangitis.
• If simple symptomatic cholelithiasis (no signs of infection or other biliary obstruction) and pain is controlled, patient can often be discharged from ED with outpatient surgical follow-up.

Symptomatic Cholelithiasis vs Cholecystitis on Ultrasound

Cholecystitis may have the following:

1. Gallstones present in gallbadder
2. Sonographic Murphy’s sign
   • Maximal tenderness over the most anterior portion of GB as defined with US imaging
3. Wall thickness of gallbladder over 3 mm
   • Be sure to measure GB wall thickness at anterior aspect to avoid false positive increased secondary to posterior acoustic enhancement!
4. Pericholecystic fluid

These findings should be used in conjunction with lab results to help identify diagnosis on spectrum of biliary disease.

References:

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Ch 79: Pancreatitis and Cholecystitis. Judith E. Tintinalli

Soni, Nilam, et. al. Point of Care Ultrasound, 2nd Edition. Ch 27: Gallbladder 

A 2 year old female with no past medical history presents for a nasal foreign body. The patient’s mother states that the child approached her earlier this evening while pointing at her nose. When the mother looked into the child’s right nostril, she noticed something metal. Vital signs are normal for age. On exam, the patient is in no acute distress with mucus coming from the right nostril and a silver metallic object lodged in the nare. A skull x-ray is obtained and shown below. The area of interest is included and zoomed in. What’s the diagnosis and what’s the appropriate management?

Answer: Nasal button battery – emergent removal in ED

• Button batteries are distinguished on plain films most commonly by the “double ring sign” in AP view which is best shown in the lateral film above. Lateral views of a button battery may also show a step-off which is also evident in the AP x-ray.
• Management of a nasal button battery differs from many other foreign bodies due to the risk of rapid necrosis and septal perforation in as little as 7 hours.
• ED methods for removal of nasal foreign bodies include the “parent kiss” technique or bag valve mask to expel the foreign body, forcep or suction catheter removal, or use of a foley balloon.
• In this case, the object was ultimately removed by ENT with procedural sedation in the ED.

References:

Cohen JS, Agrawal D. Nose and Sinus Disorders in Infants and Children. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e.

McGraw Hill; 2020.Loh  WS, Leong  J, Tan  HK: Hazardous foreign bodies: complications and management of button batteries in the nose. Ann Otol Rhinol Laryngol 112: 379, 2003. [PubMed: 12731636]