By C. Dixon, J. Benalcazar, K. Bourgeois, A. Cheng, N. Isic, J. Yelena Imele Itjoko

7-year-old African-American male brought to ED by his mother with peeling rash to face, axilla, and groin, onset one day. Mother reported abdominal pain, nausea, and three episodes of vomiting for two days prior, and decreased urine output from umbilical urostomy, which appeared in well-cared for condition. Patient afebrile on arrival, tolerating oral fluids only. Historyincluded obstructive uropathy with posterior urethral valves removed, stage 3 chronic kidney disease (CKD), and neurogenic bladder. Prior hospitalization for urosepsis and fecal impaction, with surgical intervention after colonoscopy revealed embedded glass, carpet, nail clippings, and pistachio shells in rectal wall, with epidermal abrasions surrounding the anal sphincter. Current medications included amlodipine and oxybutynin. Bloodwork revealed elevated WBCs, creatine, ESR, lactate, and C-reactive protein, with decreased sodium and chloride. Urinalysis revealed presence of nitrites, bacteria, WBCs/RBCs, and leukocyte esterase. Abdominal CT identified marked amount of stool in rectum with thickening of the sigmoid colon and rectum. IV fluids and antibiotics started prior to transfer to PICU. Inpatient initiation of successful bowel protocol upon admission. Patient transitioned to spot dosing of Vancomycin and Meropenem for impaired renal function. Allergy consult suggested Triamcinolone for skin rash, deemed exfoliative dermatitis secondary to drugs/infection. ID consult diagnosed skin rash compatible with staphylococcus scalded skin syndrome (SSSS), initiated Ceftaroline to cover MRSA/gram negative bacteria, discontinued Vancomycin and meropenem. Patient’s bloodwork returned to baseline, and symptoms gradually improved. Through careful interdisciplinary assessment, what initially presented as possible child abuse ended in successful diagnosis of SSSS. Thorough elimination of differential diagnosesincluding Steven-Johnson Syndrome, exfoliative dermatitis, Kawasaki’s disease, and bacterial v. physical origin of skin condition was key in correctly identifying and treating this patient’s condition. While considering the patient as a whole yields invaluable information, it is equally as important to follow presentation, history, and diagnostics to prevent biased diagnoses.