SAEM Clinical Image Series: A Multifactorial Skin Eruption

A 9-year-old male with no past medical history, brought in by his mother to the ER with a new rash on his face and torso. The rash began 10 days ago. On the day he developed the rash, the patient noted swimming in a newly chlorinated outdoor pool. That same day he also played with freshly picked oranges and limes outdoors with his friends, having squeezed the juices onto his head and body. He developed a non-painful, non-pruritic, hyper-pigmented rash on his left cheek.

Over the course of 3 days, the patient and his family went on a trip to a local river, during which the rash evolved to scattered patches on his face and dorsum of his hands with an associated burning sensation exacerbated by contact with hot water or sunscreen. He received outpatient treated by a medical provider at day 3 for presumed infection with both oral and topical antibiotics. He completed the antibiotics, with worsening of his skin lesions. They have since formed blisters and affected his torso.

The patient never had any similar symptoms, or allergies. He had no sick contacts or travel outside the U.S. He denies any history of trauma, thermal burns, or arthropod exposure. The patient has not had fevers, respiratory symptoms, gastrointestinal symptoms, or urinary symptoms.