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An Adolescent Male With a Rash

A 15-year-old previously healthy male presented to the emergency department (ED) with a 2-cm nodule with overlying fluctuance in the right axilla. The right axillary nodule was first noted 1 week prior to presentation with progression in size over the past week. The patient reports trauma to the area from shaving. He initially had intentions of presenting to his primary care physician; however, on reporting symptoms of fever, nausea, chills, and one episode of emesis he was referred to the ED. The patient also noticed a faint erythematous rash on his chest that morning. On presentation in the ED he was notably afebrile, tachycardic to 125, tachypneic to 20, and having a widened pulse pressure (115/47). He was well appearing with a benign cardiopulmonary and abdominal exam. His rash, however, had intensified and spread to his chest and upper extremities and was characterized as confluent, erythematous but blanching to pressure. A 2 × 3 cm right axillary area of induration with overlying fluctuance and surrounding erythema suspicious for an abscess was also appreciated. While in the ED the patient appeared clinically ill with malaise, chills, and fevers to 103.8°F. His vitals became more unstable with blood pressure of 102/57, pulse of 114, respirations of 20 breaths per minute, and oxygen saturation of 99% on room air. He was fluid resuscitated with 1 normal saline bolus in the ED with good response. Additionally, the abscess was confirmed by ultrasound, and an incision and drainage was performed. Blood and wound cultures were obtained and he was started on empirical antibiotic coverage of intravenous vancomycin and clindamycin. His laboratory values at presentation were significant for an elevated white blood cells count to 16.5 with a left shift and C-reactive protein elevated to 128.1 mg/dL. His other cell lines were within normal limits. He had a comprehensive metabolic profile that was unremarkable outside of slight elevation of total bilirubin (2.1 g/dL) and γ-glutamyl transpeptidase (64 U/L).