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Tuesday, September 4, 2012

A rash of rashes (Don't fear the fever, Part 2)

With all the fun and exciting things that happened to our family this summer, we also had two crummy illnesses thrown into the mix, just to keep us on our toes (or should I say, knees?).

My husband and I had planned a getaway trip to Boston at the end of June, but my daughter had other plans: she got pretty sick about a week or so before our trip. I blogged about the experience, and mainly how we were deciding not to overdo it on the Tylenol/Motrin thing and just let her body do its thing to fight whatever she had. And of course, people wanted to know how things turned out.

After a visit to the peds, he diagnosed her with Coxsackie Virus, based on her rash features: sort of random, slightly raised red bumps. She had it on her hands, and it definitely looked like HFM (hand-foot-mouth). She also had it in a cluster on her torso, but nothing on her feet or in her mouth. I thought perhaps some Tylenol to keep her comfortable and we'd just ride it out, thankful that she didn't have the telltale mouth sores that many kids get.

Well, I was wrong. We ended up in pediatric urgent care, where they observed that her rash features had changed - she had something called erythema multiforme. They decided they couldn't tell conclusively if it was a viral agent or something called Kawasaki Disease, a vasculitis (which causes swelling of the blood vessels) that seems to affect primarily Japanese and American children. While it's pretty rare, it can pose serious complications if left untreated, including catastrophic heart damage that can lead to sudden death episodes. (Think John Travolta's son) W.T.F. I freaked. I held onto the notion that perhaps this was a particular strain of Coxsackie Virus, which can cause erythema multiforme.

In the end, they decided to treat her as if she had Kawasaki's, because they felt that the benefit outweighed the risks. She had a mixed bag of symptoms, some of which met Kawasaki's criteria. They waited at least a day and a half to treat her simply because the medication is insanely expensive and they weren't 100 percent sure - they even called in a delightfully old gentleman in infectious diseases who, I later suspected with horror, was a retired physician they called in to consult. Heck - the guy even carried a doctor's bag.

She had fluid around her heart - a possible sign of Kawasaki's, or something viral, or simply from being sick. Red, strawberry tongue - also a sign of Kawasaki's, but not conclusive enough to diagnose, and could also be a sign of dehydration. Whatever it was, it was kicking her butt. They gave her a round of IV IG - intravenous immunoglobulin, purified blood plasma that is supposed to boost her immune system and apparently costs around $3,000 per dose. Thankfully she tolerated it well and was able to leave the hospital after 2 1/2 days.

I still don't want to "fear the fever," but when it's accompanied by a rash - especially one that you've never seen before - it's probably a cause for concern. In the mom's guide to rashes stuff I've seen, this one hasn't been listed, and even though Kawasaki's is rare, it does need to be treated swiftly. One definite cause for alarm with regards to fever is one that lasts more than four or five days, which was a concern to doctors - at one point I was out in the hallway with the attending and his medical students, and felt like I was stuck in a surreal episode of House M.D. I don't ever want to do that again.

Just for your memory files, this is what it typically looks like after the red spots change - target or bullet-like lesions that sort of fan out from the center. It kind of reminded me of a head of cauliflower.

Erythema multiforme. Photo: Wikipedia Commons.
Our last hurrah for the summer was a trip to my mom's in Ohio, where I unfortunately spent the week with a sore throat. It would subside some during the day, but at night it was almost unbearable, and Advil only made a slight difference. At one point as I tried to fall asleep, I thought I was choking on saliva and a moment of panic set in. But otherwise I could function - I didn't feel too terrible during the day, and if I did, chalked it up to crummy food and not enough sleep. I thought I had a cold, until I suddenly realized it was getting worse instead of better, and hadn't gone away in the usual time a sore throat from a cold does. Do I have strep throat?! I thought. I wasn't sure.

I think I've had strep throat once - I can't even remember if that's what it was - and wished I had thought more about seeing the doctor when we returned home. I had cold symptoms the following week after the sore throat went away, and didn't think any more of it. Until I developed quarter-sized red bumps on my lower legs, serious joint pain in my knees and ankles, and just generally still felt like crap. I thought maybe it was from shaving. After a few days I decided I couldn't take it anymore and headed to the doctor.

I had done some googling but wasn't sure what I was looking at was really what I was looking at. I ended up seeing the Pretend Doctor, and after that visit have decided never again. I like my regular doctor, but I'm not sure where he found this person: she said it looked like a vasculitis (similar to the rash my daughter had), and I silently freaked out. But she also blubbered on about a "chest X-ray, punch biopsy," and a bunch of other stuff that had me wondering. I absently said I would like a second opinion from the doctor (thank God he was there that day) and he cheerfully came in and examined me quickly. His diagnosis was pretty succinct and seemed to match up with what I had read, and Pretend Doctor got a tad defensive (and after Dr. Real Doctor left, said, "I know what I'm talking about," a little confidently), but who cares. No punch biopsy for me (which I read later is only required in cases where the cause cannot be determined, and mostly for localized outbreaks or something, whatever that means). I had to laugh when I came across the words "Any experienced doctor should be able to diagnose based on clinical symptoms. Rarely is a biopsy needed." Hahahaha (this is me laughing hysterically in my altered mental state)

The final word was that I had developed erythema nodosum, a rash that (most commonly, I read!) is caused by a recent strep infection. I felt like a detective. I now knew more about stupid erythematous rashes than most people would care to, and was sick of the word 'erythema.' I had punched in that stupid search criteria into my computer so many times I barely had to type the letters e r y before the term came up.

In case you've never heard of it, erythema nodosum is a bumpy rash that is most often confined to the lower legs and shins, and feels pretty much like you played rugby for six hours in high heels and then were kicked in the shins by the entire team. It also includes ankle swelling, joint pain and general malaise, and as a result I've been sucking down more Advil than I ever thought possible.

I know some are skeptical of the effectiveness of taking antibiotics for strep infections, but I'm wondering if this could have all been avoided if I had seen the doctor sooner. The pain at times is almost unbearable, and I have a pretty high tolerance for pain. Sometimes Motrin works well, sometimes not. I'd rather risk potentially disturbed gut flora from a course of prophylactic antibiotics (which I'm on anyway right now, just in case) than deal with this again. Cases of rheumatic fever are virtually non-existant in the US now as a result of antibiotics after strep throat, but some people report pockets recurring - which I'm wondering is either because parents aren't recognizing the sore throat or think it's unnecessary and don't want to contribute to antibiotic abuse. I can appreciate that, to some degree. But even if don't have strep complications, you can still have rheumatic fever, which can have serious, life-long (and sometimes life-threatening) complications.

Erythema nodosum. Photo:
Rheumatic fever is pretty rare in adults and mostly strikes children (like it did my grandma as a kid, before penicillin was even discovered) but that doesn't stop me from worrying about it, of course. In the meantime, I have a date with the heating pad. This should hopefully resolve itself ... in about three to six weeks. *frown*

More reading:
Your child has a rash: do you know what to do? 


Karli said...

I'm pretty crunchy, but strep is something I wouldn't ever mess with. I watched my amazing, fun loving nephew develop OCD and panic attacks. He developed PANDAS due to an untreated strep infection. Antibiotics definitely have a time and a place.

The Deranged Housewife said...

Oh yes, I've read about PANDAS. What a nightmare!! I hope he's doing better.

baseballmom61 said...

A gentleman I worked with lost his wife to a simple case of Strep throat that went untreated for too long. She developed complications as the virus mutated. She left behind a four year old son and a devastated husband.

The Deranged Housewife said...

Well, here's an update, sort of: The strep culture came back negative. It could be mono, although I think I feel pretty good for a person with mono. The other choices are too horrific to think about, so I'm hoping it was simply an "extreme reaction to a virus" (as one source put it) and that we can happily move on from here. *cringe* We shall see.