A previously healthy, 16-year-old Hispanic boy initially presents to the clinic with a 5-day history of tactile fevers, achy malaise, congestion, and a dry cough. He was afebrile with negative rapid strep and monospot tests, but was prescribed fluticasone, benzonatate, and ibuprofen for a presumed upper respiratory infection. He was encouraged to return if symptoms did not improve.
At home, the patient's cough persisted with the addition of several episodes of nonbloody, nonbilious posttussive emesis. On day 9 of illness, he developed oral vesicular lesions associated with discomfort when swallowing solid foods, prompting a visit to the local emergency department (ED). There, his temperature was 102.92°F, but physical exam and chest imaging performed at that time were reassuring for a safe discharge home with close follow-up after being given a 5-day course of azithromycin for bronchitis (Figure 1).
By day 12 of his illness, the patient’s course was worsening. The vesicular oral lesions were friable and beginning to bleed. His coughing episodes were increasingly frequent and produced blood-streaked sputum. Severe odynophagia prevented him from consuming both solids and liquids. A complete physical exam by his pediatrician at follow-up revealed red, round, ulcerative lesions of the ventral penile shaft along with skin peeling and scant mucus discharge at the urethral opening. Because of his poor fluid intake and progressing symptomatology, he was quickly referred back to the ED and admitted for continued evaluation and management (Figure 2).