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Images of Memorable Cases: Case 90

Module by: Herbert L. Fred, MD, Hendrik A. van Dijk

http://rup.rice.edu/memcases-button.jpg

Case_90-pres1-1.jpg

Case_90-pres1-2.jpg Case_90-pres1-3.jpg

This 25-year-old woman suddenly developed shaking chills, confusion, and a temperature of 103° F. On physical examination, she had numerous petechiae in her palpebral and bulbar conjunctiva (top image) and over the shoulders, arms and upper anterior part of her chest (bottom images).

90. Systemic fat embolism

Thirty hours before onset of her fever and chills, this patient fractured her right femur in an auto-pedestrian accident. She ultimately made a full recovery without receiving antibiotics.

In patients with recent fracture of the long bones, the best (and often the first) evidence of systemic fat embolism is the abrupt appearance of petechiae in a characteristic distribution—conjunctivae, base of neck, axillae, and upper anterior part of the arms, shoulders, and chest. If the petechiae develop at all, they usually become visible 24 to 36 hours after the injury. They typically persist for three to four days, then fade rapidly. Their number has no relation to prognosis.

The sudden appearance of fever, chills, and petechiae ordinarily suggests infection, particularly meningococcemia. But if the history indicates recent fracture of a long bone, systemic fat embolism is likely.

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