CASE 4

HPI: 8 y/o girl of Mediterranean descent returned to the ER with worsening symptoms. She had been seen 5 days earlier c/o fever, sore throat & a pruritic rash. The H&P on that visit described the rash as like “sandpaper,” & the pt was Dx with scarlet fever and given Rx for Amox. She described no improvement on her return visit, now c/o N/V as well.

PE: Vs – wnl; CV – RRR; Resp – CTAB; Abd – soft, NT/ND, good BS; Skin – slightly dry mucosa, the erythema is both blanching with areas of petechiae/excoriation; appearance & rash as below

What’s your diagnosis?

Answer: Although her initial presentation did sound like scarlet fever, the patient was noticeably jaundiced on her return visit. Her conjunctive was also quite icteric. (Unfortunately I cannot show her eyes to protect her privacy.) It is important to remember that hyperbilirubinemia can also cause pruritis.

Hyperbilirubinemia is usually classified as conjugated or unconjugated. Clinically, it may be easier to think of hyperbilirubinemia as a sign of:

- inflammation or infection of the liver (conj)

- obstruction of the biliary tree (conj)

- massive hemolysis (unconj)

Unless the patient has a mild viral hepatitis or a slowly deteriorating cirrhotic liver, it is prudent to admit these patients for monitoring and further work-up. In someone of Middle Eastern descent, you should consider hemolysis from Thalassemia Major or G6PD deficiency. This patient’s labs work showed a normal CBC, but elevated LFTs. An US showed biliary duct obstruction and the patient was admitted.