19 yo F with a rash and SOB

Based on a case provided by Lauren Brown, MD.
Edits, graphics and teaching points by Yilin Zhang, MD.


OBJECTIVES:

  • Evaluation and differential diagnosis of peripheral eosinophilia

CASE:

19 yo F with mild asthma presents with fevers, a new rash, dyspnea and cough x 1 week ago. She first noted a pruritic, migratory rash on her arms/legs that has improved with daily cetirizine. She reports nasal congestion and occassional production of yellow mucus. She’s been increasingly short of breath and wheezy and has needed to use her albuterol inhaler several times a day. She denies any sick contacts, sore throat, myalgias/arthralgias.

Her PMH is notable for exercise-induced asthma with rare albuterol use. She started having bloody diarrhea one month ago and was diagnosed with colitis (possibly IBD) on colonoscopy ~ 10 d prior to presentation for which she received 1 dose of ciprofloxacin. She also has a history of recurrent sinus/ear infections and completed a 2 week course of cefdinir 1.5 months prior to presentation. She takes no other medications and denies any substance use. She is a college student from CA. In the last year she has traveled to Hawaii only but has traveled to Europe and Mexico in the distant past.

On exam, she is afebrile here (up to 39.5C at home), HFs 110-130s, RR 18, BPs 100-110/60-70s, SaO2 96% on 2L NC. She has mild expiratory wheezes on lung exam. Skin exam is notable for this rash:

How would you describe this rash?


CASE CONTINUED:
Labs
  • BMP normal
  • CBC notable for a WBC of 12k (2k eosinophils), hct 32%, plts 517k
  • LFTs normal
  • ESR 106, CRP 139

What is your differential for her laboratory abnormalities? 


CXR

A subsequent CT shows the following:

What are some unifying diagnoses for her imaging and laboratory findings? 

What additional work-up do you want now? 


FINAL DIAGNOSIS AND OUTCOME:

TAKE HOME POINTS:


REFERENCES:

  1. Roufosse, F & Weller, PF. Practical approach to the patient with hypereosinophilia. Journal of Allergy and Clinical Immunology. 2010; 39-44.
  2. Bell, DJ & Armini, B. “Crazy Paving.” Radiopaedia. Accessed at: https://radiopaedia.org/articles/crazy-paving