Case Report

An 18-year-old male with Down syndrome due to Trisomy 21 and autism presented with complaints of a diffuse pruritic rash, that progressively worsened over the course of 1 year. The patient’s mother recalled the rash initially began around the bilateral eyebrows and hairline and progressively spread to the other parts of face, trunk, and upper extremities. He had been seen prior to admission twice and treated with oral prednisone and had mild improvement of symptoms. After the steroids were completed, the rash quickly returned in a more severe form, and he was then diagnosed with psoriasis and was prescribed topical steroids, which he did not tolerate due to pain during application of the ointment. Per the patient’s mother, he had been brought to the pediatric emergency department at this time because she was concerned that he had stopped eating and drinking, likely due to the pain caused by cheilosis and was admitted to the hospital. The patient had substantial weight loss of 30 pounds over the prior 5 months. The patient was admitted for the severity of his rash and pain management, which prevented him from eating and drinking.

His medical history included a diagnosis of Down syndrome and autism. His surgical history included cardiac surgery at the age of 5 months due to (unknown) cardiac defect, orchidopexy at 2 years, and tonsillectomy at 5 years of life. The patient lived with his parents in a mobile home. At baseline, the patient could not speak or chew solid foods, but was able to walk with assistance, and understood simple commands. Patient was able to eat pureed food on his own before developing the rash on his hands. His parents also had symptoms of a pruritic erythematous rash.

On physical exam, he was alert and active. His temperature was 101.4°F, blood pressure was 102/66, heart rate was 94, respiratory rate was 16, and oxygen saturations 98 on room air. His weight was 41 kg and his height was 157 cm, putting him on the <1 percentile on Centers for Disease Control and Prevention (CDC) (boys, 2-20 years) weight-for-age and <1 percentile based on CDC (boys, 2-20 years) stature-for-age. His scalp had multiple erythematous papules in linear fashion along with multiple crusted lesions, his eyes had crusted lesions involving upper and lower eyelids bilaterally. His ear exam included erythematous papules and crusted lesions involving both ears, nose exam with multiple erythematous papules, and neck with multiple erythematous papules in linear fashion along with multiple crusted lesions. His lung exam was clear to auscultation, heart exam with regular rate and rhythm, no murmur, and abdomen exam with normal bowel sounds, soft, non-distended, no hepatosplenomegaly or masses. His skin exam revealed multiple erythematous papules in linear fashion along with multiple crusted lesions all over the body and burrows seen between fingers.

This case study did not require institutional review board’s approval. There was no conflict of interest and no funding for this case report.