Case: Dermatology #2
Case Study: Dermatology Cases for Primary Care
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“My son has a rash on his arm that’s getting worse by the hour!”
Case #2: Jeremy is a 10-year-old boy brought in by his mother because of a rash that ‘‘keeps getting bigger” and that has become painful to touch. He also complains of nausea, vomiting, and general malaise since last evening. He had been fine up until then. He had spent the day helping his mother move summer clothes down from the attic. He denies seeing any ticks, ants, or spiders, but thinks he might have felt some sort of sting on his arm.
Social History: Patient is a healthy 10-year-old boy living in Missouri with his parents and 2 siblings. No history of allergies or skin diseases. Takes no medications and is active in Little League and town soccer. He is up to date with all his immunizations.
Physical Examination
Pale, thin boy in obvious GI distress.
Height 51”, weight 67 lbs. BP 115/75
Review of Systems: WNL
Skin: Area around the rash is painful to touch. Two fine puncture marks are visible. There is an irregular erythematous ring around the site of the bite with a bluish center that has blistered to about 2 cm.
How would you proceed?
Published on May 17, 2010
Updated on May 24, 2010
Follow-up
Jeremy might have been bitten by a brown recluse spider. These spiders are indigenous to an area that spans eastward roughly from southeastern Nebraska and the eastern half of Texas to the western part of Georgia. They hibernate during the fall, winter, and early spring, with the highest incidence of bites occurring between April and October. They prefer hot, dry, abandoned, or otherwise quiet environments such as woodpiles, vacant buildings, attics, under beds, and in closets. When Jeremy helped his mother move the summer clothes down from the attic, it is likely that he was exposed at that time.
The majority of brown recluse spider bites heal within a few weeks and do not require extensive medical treatment. Initially, bites should be cleaned thoroughly and rest, ice, compression, and elevation (RICE) treatment should be initiated. Mild cases characterized by pruritus, erythema, and any obvious skin punctures can be treated by administering acetaminophen and antihistamines and possibly a tetanus vaccine. Jeremy and his mom should be advised to return for follow-up if symptoms do not abate; at that time prophylactic antibiotics should be considered (erythromycin or cephalosporin) to prevent cellulitis. While systemic symptoms are rare in adults, they are more common in childreren.
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