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A 22-month-old male with a rash on arms, legs
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A 22-month-old male was sent by his pediatrician to the ED in January for evaluation of a rash on his arms and legs. Parents report that he first developed “bumps” on the flexor surfaces of bilateral knees and legs, and extensor surfaces of bilateral upper arms and elbows 5 days before his ED visit.
At onset of the rash, he also had a low-grade fever for 1 day and small papular lesions around the mouth. No vesicles or pustules were noted. He was seen by his pediatrician, and the rash was suspected to be a coxsackievirus exanthem.
He was also diagnosed with otitis media and was taking the prescribed oral amoxicillin. The skin lesions gradually became dark and crusted, and a few new lesions continued to appear on the extremities. He had a normal appetite, diet and activity level throughout. No pruritis or discomfort was noted.
Figures 1-3. The child first developed “bumps” on the flexor surfaces of bilateral knees and legs, and extensor surfaces of bilateral upper arms and elbows 5 days before his ED visit.
Source: Pittalwala R
His medical history was unremarkable, except for mild eczema, and his immunizations were up to date. There was a known recent contact with hand, foot and mouth disease (HFMD) at the day care center he attended.
On exam in the ED, he was well appearing, happy and playful. He was eating a snack and appeared to be in no discomfort. He was afebrile, and vital signs were within normal range. Physical exam was remarkable only for the skin lesions. He had multiple clusters of crusted hemorrhagic papules on the flexor surface of bilateral lower legs from below the buttocks, extensor surface of bilateral arms from mid upper arms and a 2-cm area on the left lower lateral abdominal wall. There was no involvement of the palms and soles.
Source: Pittalwala R
No oral lesions were seen, and there was no involvement of the neck, buttocks, inguinal or axillary areas. There were a few small, 1-mm erythematous papules seen around the angles of the mouth. There were also two to three more recent scattered papulovesicular 1-mm lesions seen on the left ankle and right wrist. The rash was nontender, with no petechiae or purpura. There were no pustules or honey crusts, and no deep or punched-out ulcers; no target lesions and no mucosal or nail involvement.
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A complete blood count showed no elevation of white count and normal values for hemoglobin and platelets. A swab from the lesions was sent for viral polymerase chain reaction. He was discharged home with a presumptive diagnosis of viral exanthem. This was in view of recent reports of more severe and atypical HFMD rash associated with outbreaks of a strain of coxsackievirus.
The swab was positive for enterovirus PCR and negative for herpes simplex virus and varicella zoster virus PCR. On follow-up visit with his pediatrician a few weeks later, the rash had resolved and he had residual hyperpigmentation.