Case involves the failure to diagnose and treat DRESS syndrome. Client has a past medical history of anxiety, depression, oppositional defiant disorder (ODD), and ADHD. Based on the records, in early September, he was started on carbamazepine and olanzapine. On 10/1/2024, Amoxicillin was administered for otitis media. On 10/5/2024, he developed urticaria and a rash on chest and back from an allergic reaction to Amoxicillin.
On 10/9/2024, he presented to the ED for his rash. He was given Benadryl, dexamethasone, and famotidine as well as a 5-day course of Azithromycin and Medrol Dosepak. On October 17, 2024, he presented to another ER for worsening rash, pruritus, and shortness of breath. Evidently, there was a mild improvement after the Medrol Dosepak outpatient, but symptoms returned. Due to concern for subacute anaphylaxis, he was given IM epinephrine and dexamethasone, Benadryl, and Pepcid. Labs demonstrated eosinophilia to 31.8%. He was discharged home with an EpiPen and a second Medrol Dosepak and referred to an allergist. Upon discharge, he had a visit with his pediatrician later in the afternoon. On 10/22/24, he returned for his third visit to the ED with a rash and worsening of bilateral ear pain and nausea. The rash was thought to be due to serum sickness or an allergic reaction. He was given Decadron and Zofran as well as a Rx for Doxycycline for purulent otitis media. No mastoid tenderness.
On October 29 to November 3rd, he was admitted to a hospital for peeling rash on face and lower extremities with intermittent vomiting, also noted to have dark urine. Labs significant for leukocytosis WBC 19.3 and eosinophilia of 20%. Also notable for hyponatremia to 130 and metabolic acidosis with bicarb of 19. He was started on clindamycin due to concern of superimposed bacterial infection. On the fourth day of admission, the Clindamycin was stopped after DRESS became primary diagnosis. He was provided albumin/Lasix for hypoalbuminemia. CRP down trended and he was provided steroids with outpatient prednisone taper plan. He was discharged with a plan to f/u with dermatology and rheumatology. The day after discharge, he had a visit with his PCP where he reported excruciating pain. On November 7th, he saw an outpatient dermatologist who recommended an immediate hospital admission to Pediatric Hospital. On November 16, 2024, he was transferred to the Burn Unit at a different Hospital for evaluation where he remained for 27 days. On December 13, 2024, he was discharged from hospital, but he required readmission on December 29, 2024, over concerns for cellulitis, and bacteremia with an elevated white count and CRP. He was discharged on December 31, 2024, with a diagnosis of fever, wound infection, DRESS syndrome, ecthyma gangrenosum of the bilateral lower legs and bilateral cellulitis. Attached is a picture of client's lower extremities from January 8th of 2025.
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