Clinical Case 078: bewildering blisters, vexing vesicles?

OK, is been a while since we did a simple case – too much podcasting lately.  This one is a quick spot diagnosis.  If you do a bit of Paeds it is not tricky – hover this diagnosis seems to stump even our smartest JMOs when they first venture into Paeds practice (yes, you know who you are Dr Wright).

This is a 6 month old breastfed, thriving girl from a local community.  She is otherwise well and has really been OK except for being a bit cranky, and maybe a little off her fluids for 24 hours. She doesn’t look septic or unwell, maybe a bit flushed.

Mum is concerned about a rash – she has a fluid-filled “blister” on her anterior shin – it is filled with a clear serous fluid, maybe a bit red on adjacent skin.

lg rash


Now, what should be every diagnostic, Osler-like wunderkind Docs next move?

More history?  Might help

No – undress the kid and look in every orifice for other signs to fill in the blanks – complete the puzzle.  That is how you  fit the history to your inner database of syndromes and diagnostic triads etc.

Any spot diagnoses come to mind?






This crop of lesions: Mum says they looked like the one on her leg yesterday, then they burst

abdo rash.


OK, as always – first in with the correct diagnosis and the pathophysiological explanation plus a management plan wins the glory of being named Broome Docs Brainiac of the day.

Quick, gotta be fast to win!





Congrats to Elisha T from Canadia who has a blog called The Chart Review 

Elisha correctly diagnosed bullous impetigo. It occurs when a strain of staph secretes an epidermolytic exotoxin which splits the layers of skin to form a bulla or big vesicle.

Treatment: topical mupirocin for small areas + oral ABs for multiple, large areas (fluclox or ceph or whatever your local staph doesn’t like)

Remember to cover as they are infectious including for auto -innoculation in little kids. If recurrent they might need Staph eradication therapy






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