LAUSR

A previously healthy 17-year-old male presented to a tertiary care pediatric emergency department (ED) with a 2-week history of testicular pain, rash, and worsening mental status. His symptoms began with bilateral testicular pain 2 weeks prior to presentation. One day later, he developed a skin eruption on his fingers after using weed killer spray, which was not a pesticide. The skin eruption was presumed to be a chemical burn. This eruption spread to the entire torso involving the groin, palms and soles, and, later, his face. There was no associated desquamation. The patient also reported associated subjective fevers, chills, and night sweats. One week prior to presentation, he began to feel anxious and was noted by family to be irritable. Three to four days prior to presentation, he began to experience intermittent confusion and visual and auditory hallucinations at night. One day before, the patient was seen at an urgent care clinic for his testicular pain and penile discharge. The patient was sexually active with one asymptomatic female partner without protection, including their last encounter 4 days prior to presentation. His ultrasound showed epididymitis, and he tested negative for gonorrhea, chlamydia, syphilis, and HIV. The patient was given empiric ceftriaxone and discharged with 14 days of doxycycline. However, the patient presented to our ED the next day with worsening testicular pain. During the encounter, he reported exposure to liquid mercury, which had been brought home by his father from work about a month prior, which was about 2 weeks before the onset of symptoms. He played with this mercury substance twice, juggling it between his hands, with each episode lasting less than 10 minutes. He spilled the substance on his bedroom carpet, which he vacuumed. He denied ingesting or vaping the mercury. No other family members had similar symptoms. He denied recent travels, including camping and hiking. On examination, the adolescent was diaphoretic, tremulous, and anxious. He complained of significant testicular pain. He was hypertensive (158-193/93-105 mm Hg), tachycardic (110-120 beats per minute), tachypneic (20-26 breaths per minute), and afebrile. His testicles were of normal size and color, both descended, tender to palpation without mass or rash, and had normal cremasteric reflexes. His penis was circumcised and normal appearing without discharge or lesions. He had maculopapular erythematous rash on the forehead, neck, torso, genitals, and extremities, including palms and soles. The patient had a Glasgow Coma Scale score of 15 but reported intermittent auditory and visual hallucinations while in the ED. Initial laboratory results in the ED included the following: white blood cell 13 800/μL, hemoglobin 15 g/ dL, platelet 288 000/μL, and positive tetrahydrocannabinol on urine drug screen. Otherwise, the following investigations were within normal ranges: brain natriuretic peptide, C-reactive protein, cerebrospinal fluid analysis, coagulopathy studies, comprehensive metabolic panel, coronavirus disease 2019 rapid screening, FTA antibodies, lipase, rapid HIV, rapid plasma reagin test, rheumatoid factor, serum histoplasma antigen, thyroid-stimulating hormone, treponema pallidum antibody, troponin I, urinalysis, and culture. Computed tomography scan of head without contrast and chest X-ray also showed no pathology. On admission, blood and urine samples were collected for heavy metals screening. 1072635 CPJXXX10.1177/00099228211072635Clinical PediatricsKim et al research-article2022