September 2003

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History & Physical Exam: A previously healthy 7-year-old girl presented from an outside hospital for evaluation and treatment of swelling of the head and neck. The patient's mother reported that the patient was sleeping on a rarely used hide-a-bed when she awoke in middle of the night crying and complaining of lip pain. Within hours, the patient's mother noted significant swelling of the left lip and face. The patient was taken to a small local hospital. Despite treatment with antihistamines, epinephrine, and IV steroids at the outside hospital, the patient experienced rapidly progressing facial and neck swelling requiring transfer to Children's Hospital. Shortly after admission, the patient was intubated due to a compromised airway. The patient remained intubated in the pediatric intensive care unit for 5 days. As the swelling slowly resolved, a necrotic papule became apparent on the left lower lip. A dusky depressed linear plaque in a gravitational pattern also developed along the left chin and mandible (Figs 1,2).

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