What's Your Diagnosis?

A 16-year-old male athlete presents with fluid-filled lesions

Figure 1. Popliteal lesions.
Source: James H. Brien, DO
James H. Brien

A 16-year-old male presented with a few fluid-filled lesions (vesicles) on his right popliteal area, accompanied by significant pruritus. As the patient continued scratching the area, new lesions continued to appear. After two visits to the primary’s office, two courses of oral antibiotics and one ED visit, he was admitted to the hospital for IV antibiotics for a presumed infection. The patient was previously healthy, with no underlying chronic or acute diseases, and he had no fever. He is a high school athlete, who was running track when this condition started. He spends a lot of time in the grass stretching prior to his track workouts. He denied any injury to the area, and did not recall any unusual insect bites. His exam was that of a healthy 16-year-old male, with the only abnormal finding being this unusual area of mild-to-moderate diffuse erythema, with some patches of lesions containing small pustules or vesicles, which initially appeared to resemble “kissing lesions,” as shown in Figure 1. Within a few days, these popliteal lesions progressed to more severe, fluid-filled lesions, with some drainage of serosanguinous fluid (Figure 2). The patient also had some discrete, smaller lesions appearing on various other parts of his body (Figures 3 and 4).

Figure 2. The same lesions, several days later.

On admission, the lesion was swabbed for culture and herpes simplex virus (HSV) PCR. He was then started on IV acyclovir and clindamycin, as well as topical steroid cream. The lesions began to improve, but the culture and HSV PCR were negative.

Figures 3 and 4. Smaller lesions appeared on various other parts of the patient’s body.

What’s your diagnosis?

A. Contact dermatitis

B. Eczema herpeticum

C. Candida dermatitis

D. Group A streptococcal cellulitis

The best fit for this diagnosis would be contact dermatitis (choice A). The onset is temporally associated with spending time every day stretching on the ground before working out for track. It is likely that he came in contact with either poison ivy or some other rhus plant during one of these days before working out, and it probably spread to other parts of the body by autoinoculation. This can result in discrete streaking or diffuse swelling, with patches of erythema (Figures 5 and 6). The primary symptom was itching with vesicle formation, particularly the right popliteal area. Having failed oral antimicrobial therapy, along with negative testing, the improvement was likely due to topical steroids.

Figures 5 and 6. Reaction to poison ivy can result in discrete streaking or diffuse swelling and erythema.
Source: James H. Brien, DO

Eczema herpeticum would not likely occur without a history of eczema or atopic dermatitis — plus, the HSV PCR test was negative. Otherwise, it could look very similar (Figure 7).

Figure 7. Severe eczema herpeticum in the popliteal area.

Candida dermatitis is fairly common in babies with diaper rashes and in patients who have prolonged intertriginous moisture, such as a baby’s anterior neck (Figure 8). It usually presents as a smooth, pink, wet rash. Such was not the case with this patient. For Canada to thrive, it needs moisture and warmth. Areas that are normally dry usually do not get secondarily infected with C. albicans in those with intact immune systems.

Figure 8. Severe Candida dermatitis of the anterior neck.

Group A streptococcal cellulitis can occur anywhere, but it would look more erythematous and smoother, perhaps with lymphangitis (Figure 9). Also, with early antimicrobial therapy, one might expect improvement in the outpatient setting.

Figure 9. Group A streptococcal cellulitis.

Disclosure: Brien reports no relevant financial disclosures.

Figure 1. Popliteal lesions.
Source: James H. Brien, DO
James H. Brien

A 16-year-old male presented with a few fluid-filled lesions (vesicles) on his right popliteal area, accompanied by significant pruritus. As the patient continued scratching the area, new lesions continued to appear. After two visits to the primary’s office, two courses of oral antibiotics and one ED visit, he was admitted to the hospital for IV antibiotics for a presumed infection. The patient was previously healthy, with no underlying chronic or acute diseases, and he had no fever. He is a high school athlete, who was running track when this condition started. He spends a lot of time in the grass stretching prior to his track workouts. He denied any injury to the area, and did not recall any unusual insect bites. His exam was that of a healthy 16-year-old male, with the only abnormal finding being this unusual area of mild-to-moderate diffuse erythema, with some patches of lesions containing small pustules or vesicles, which initially appeared to resemble “kissing lesions,” as shown in Figure 1. Within a few days, these popliteal lesions progressed to more severe, fluid-filled lesions, with some drainage of serosanguinous fluid (Figure 2). The patient also had some discrete, smaller lesions appearing on various other parts of his body (Figures 3 and 4).

Figure 2. The same lesions, several days later.

On admission, the lesion was swabbed for culture and herpes simplex virus (HSV) PCR. He was then started on IV acyclovir and clindamycin, as well as topical steroid cream. The lesions began to improve, but the culture and HSV PCR were negative.

Figures 3 and 4. Smaller lesions appeared on various other parts of the patient’s body.

What’s your diagnosis?

A. Contact dermatitis

B. Eczema herpeticum

C. Candida dermatitis

D. Group A streptococcal cellulitis

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The best fit for this diagnosis would be contact dermatitis (choice A). The onset is temporally associated with spending time every day stretching on the ground before working out for track. It is likely that he came in contact with either poison ivy or some other rhus plant during one of these days before working out, and it probably spread to other parts of the body by autoinoculation. This can result in discrete streaking or diffuse swelling, with patches of erythema (Figures 5 and 6). The primary symptom was itching with vesicle formation, particularly the right popliteal area. Having failed oral antimicrobial therapy, along with negative testing, the improvement was likely due to topical steroids.

Figures 5 and 6. Reaction to poison ivy can result in discrete streaking or diffuse swelling and erythema.
Source: James H. Brien, DO

Eczema herpeticum would not likely occur without a history of eczema or atopic dermatitis — plus, the HSV PCR test was negative. Otherwise, it could look very similar (Figure 7).

Figure 7. Severe eczema herpeticum in the popliteal area.

Candida dermatitis is fairly common in babies with diaper rashes and in patients who have prolonged intertriginous moisture, such as a baby’s anterior neck (Figure 8). It usually presents as a smooth, pink, wet rash. Such was not the case with this patient. For Canada to thrive, it needs moisture and warmth. Areas that are normally dry usually do not get secondarily infected with C. albicans in those with intact immune systems.

Figure 8. Severe Candida dermatitis of the anterior neck.

Group A streptococcal cellulitis can occur anywhere, but it would look more erythematous and smoother, perhaps with lymphangitis (Figure 9). Also, with early antimicrobial therapy, one might expect improvement in the outpatient setting.

Figure 9. Group A streptococcal cellulitis.

Disclosure: Brien reports no relevant financial disclosures.