What is the differential diagnosis?
(1)Steven jhonson syndrome (2) kawasaki disease (3) Measles (4)Meningococcal meningitis
Discussion of the differential diagnosis : - The fever ,rash and altered mental status raises the possibility of meningococcal meningitis but the rash is characteristically petechial and purpuric reflectig accompaning systemic vasculitis the rash is sometimes similar to that of measles but cough and conjunctivitis are usually abscent , gram stain and culture failed to reveal evidence of meningococcal meningitis , however the short course of antibiotics prior to LP reduces the chance of isolation of bacteria in CSF culture making the diagnosis difficult ,and this is the importance for molecular methods (PCR) for rapid diagnosis of bacterial meningitis . The prodrome of upper respiratory symptoms , fever and painful skin together with the cuteanous and the mucosal lesions which invoved the lips , mouth , and conjunctiva , the iris or target lesion is a pathognomonic diagnosis for erythema multiform which was present early in this patient , the morbiliform rash observed initially was confusing with the measles viral exanthem , however there was no coryza or watery eyes which is present in measles prodroma , and the rash is sometimes itchy but not burning .Kawasaki disease is an acute febrile illness affecting infants and children characterized by bilateral conjunctival congestion , with dryness ,redness and fissuring of the lips also exanthematous rash localized to the trunk with redness of the palms and soles , with desquamation ,also increase CRP and leukocytosis it is excluded by absence of painful cervical lymphadenopathy , there was no arthralgia or arthritis absence of gastrointestinal or uretheral symptoms . and the liver enzymes were normal , The patient was managed as Steven Jhonson Syndrome , the offending drug stopped (ceftriaxone ) , the patient is isolated , I.V. fluids started , dermatologic , and ophthalmolgic consultation , antihistamines are given , skin and mouth care , topical soothing application , short course of coticosteroids ,antibiotics drops and ointments , systemic antibiotics to guard against secondary infection , follow up of the patient was excellent , the patient markedly improved , fever subsided and the rash disquamated over about one week .
Diagnosis : Steven Jhonson syndrome
Conclusion :Patients with Steven jahonson Syndrome may present early in the development of the disease may not be critically ill , the clinician may misdiagnose the condition and discharge the patient , with extraordinary generalized eruption with continuous fever ,inflammed buccal mucosa , and severe purulent conjunctivitis , the case is misdiagnosed by the physician as hemorrhagic measles