Case presented by Brandon Kappy, MD

HPI: 14moF presents to the ED with diffusely spreading rash and itchiness. Two weeks ago, she received vaccines (MMR, VZV, Prevnar, Flu, HAV) at her well-child check. Following her vaccinations she experienced a tactile fever, but this resolved in 24 hours.

Three days ago, she developed an itchy, red rash on her trunk that spread to her face, scalp, arms, and legs. The next day she went to an outside urgent care where they obtained EBV and VZV blood tests and was placed on daily oral acyclovir and diphenhydramine as needed. Mom is concerned as the rash has not dissipated and continues to itch.

Mom denies that patient has had any recent viral URI symptoms; no new clothing, detergents, foods, or other exposures. No sick contacts or contacts with a similar rash. The patient does attend daycare.

PMH: Full-term, healthy infant.

Allergies: No known food or drug allergies but has developed rashes to scented wipes.

Physical Exam:

Vital Signs T 37.1 C, HR 140s, BP 89/52, RR 22, O2 100% RA

General: Well-appearing infant, appropriate for age, uncomfortable and scratching at skin

HEENT: Normocephalic, atraumatic. EOMI, no conjunctival erythema/injection. TMs clear.  Oral mucosa moist.  No pharyngeal erythema or exudate.  

CV: Regular rate and rhythm.  Normal peripheral perfusion. Brisk cap refill.  

Pulmonary: Lungs clear to auscultation; non-labored respirations. Breath sounds equal bilaterally.

Abdomen: Soft, nontender, non-distended, normal bowel sounds.

Neuro: No focal neurologic deficits observed. Developmentally normal.

Skin: Diffusely scattered pink papulovesicular lesions across upper and lower extremities. Several dark/brown colored papulovesicular to the back of L hand and R foot; palms are spared. Small (2mm – 5mm) erythematous maculopapular lesions across abdomen and back. The genital/back/diaper region is spared. Erythematous papules across cheek/forehead/mandible. No mucosal or eye involvement. No crusting or weeping of lesions.

After your action(s) in the previous question, the patient is sent home with strict return precautions and PCP follow-up.

Ten days later, the patient returns to the ED. Mom states that the treatments have not helped with itchiness. Intermittently some of the vesicular lesions will spontaneously drain clear fluid.  Yesterday and today, the patient has had fevers to 102F. Otherwise continues to PO and act normally. Only other symptom is that a portion of patient’s right leg is increasingly erythematous.

Vitals: T- 38.8; HR-180; RR 20

Skin: Some lesions faded with new ones emerging; no crusting or purulent drainage. A few small lesions with clear drainage. Lateral portion of right shin, below knee, erythematous and warm with 1cm of induration noted (no rash/papule over this area). No skin breakdown or drainage.

MSK: Moves all extremities; able to flex R knee; some pain on extension as lesion is stretched. Able to move distal foot/toes normally. No effusion palpated in knee, no swelling or erythema of knee itself.

There is difficulty obtaining IV access in the patient. X-rays are obtained and show primarily anterior soft tissue edema without radiographic findings to suggest osteomyelitis.

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