Case notes
A 68-year-old Chinese woman presented to the emergency department with a pruritic rash, fever, and swelling and tenderness of the left upper extremity and vulva. One day prior to admission, she noted a distinct erythematous papule on her mons pubis. Over 24 hours, the lesion increased in size and became painful.
During the past year, the patient had been under the care of her local primary care physician for a skin rash. Topical steroid therapy for presumed eczematous dermatitis led to progressive worsening of her intensely pruritic rash. She was otherwise healthy and reported no medical problems or recent travel. A resident of New York City’s Chinatown, she lived with her husband, who also reported a pruritic rash. His had been diagnosed as extensive tinea corporis by the hospital dermatology service after a potassium hydroxide preparation showed numerous fungal hyphae.
The patient’s right labia majora and left upper arm were warm, erythematous, and edematous with focal purpuric patches ( Figure 1 ). Numerous erythematous scaly papules were present in the axilla, finger web spaces, inner thighs, and a few linear burrows. Her temperature was 102.3°F (39°C), and she was hypotensive. She had an elevated sedimentation rate and leukocytosis with a neutrophilic predominance.
A scabies preparation taken from the thigh revealed Sarcoptes scabiei mites, eggs, and scybala or mite feces ( Figure 2 ). After admission, the patient underwent extensive intraoperative debridement of necrotic soft tissue of the vulva and upper extremity. She was treated for scabies with 2 doses of ivermectin, 200 μg/kg, taken 1 week apart and permethrin 5% cream.
