This article is more than 5 years old. Information may no longer be current.
17-month-old febrile male with onset of rash, vomiting: Value of the ‘48-hour rule-out’
Click Here to Manage Email Alerts
A 17-month-old boy was admitted to a children’s hospital for fever, vomiting and rash. For 2 days before admission, he had rhinorrhea but otherwise appeared healthy. The evening before admission, he developed a fever of 103.5°F and, later, started vomiting. Overnight, he developed a lacy rash on his legs and stomach that progressed to his arms.
He was taken to the ED where he was found to be febrile and irritable but awake and alert. His laboratory results were significant for a white blood cell count of 26,000 (23% bands), normal platelets and normal coagulation panel. The patient was subsequently admitted to the hospital for a “48-hour rule-out.” Blood cultures were drawn, and he was started empirically on ceftriaxone and IV fluids.
Scattered, violaceous, crusted papules and hemorrhagic macules on the buttocks of a 17-month-old boy with fever and emesis (Figure 1). A larger, stellate, violaceous macule was also noted on the right posterior thigh (Figure 2).
Source: Krakowski AC
The next day, the patient’s original rash faded and his overall condition appeared markedly improved. Approximately 40 hours after admission, the boy developed a new, distinctive rash that consisted of scattered, violaceous, crusted papules and hemorrhagic macules on the arms, legs and buttocks, as well as the palms and soles. A stellate, violaceous macule was noted on the right posterior thigh and scattered petechiae were noted on his legs. Aside from the development of the new rash, the patient in no way appeared ill.
While the pediatric dermatology team was setting up to perform a skin biopsy to assist in the diagnosis, the patient’s inpatient team called with laboratory results that provided the answer.
This distinctive rash also involved the arms, trunk, palms and soles (Figure 3). The boy appeared otherwise healthy by the time pediatric dermatology consulted on his rash, approximately 40 hours after he had been admitted to the hospital.
Case Discussion
Answer: (D) Papular urticaria
All of the answer choices are associated with petechial or purpuric eruptions except for papular urticaria, which is caused by a hypersensitivity reaction to insect bites. The diagnosis of Henoch–Schönlein purpura or another vasculitis should be considered due to the presence of petechiae and palpable purpura, especially as the most affected areas were the legs and buttocks.
This small-vessel vasculitis causes purpura, abdominal pain, arthritis and glomerulonephritis. It is less commonly associated with intussusception and scrotal pain. Henoch–Schönlein purpura is not, however, typically associated with fever and acute illness at the onset of the skin findings.
Emily Osier
Andrew C. Krakowski
Rat-bite fever is caused by Streptococcus moniliformis after exposure to an infected rat’s saliva, urine or feces and typically presents with fever, rash, abdominal pain and arthralgias. Rocky Mountain spotted fever is caused by Rickettsia rickettsii and classically presents with the triad of fever, headache and petechial rash.
The working diagnosis of meningococcemia was suggested by the acute and simultaneous appearance of fever and petechial and purpuric eruption. This diagnosis was confirmed by blood cultures drawn as part of the “48-hour rule-out” in the ED that eventually grew Neisseria meningitidis.
In discussing N. meningitidis infections, textbooks may tend to highlight the presentation of purpura fulminans, a rapidly progressive purpura due to necrosis of the skin that may occur in cases of acute bacteremia with N. meningitidis, S. pyogenes, S. pneumoniae and S. aureus and that may be associated with muscular necrosis and systemic disseminated intravascular coagulation.
While perhaps not as dramatic as purpura fulminans, this patient’s distinctive rash (especially the stellate, violaceous lesion on his right posterior thigh) was entirely consistent with previously reported cases of N. meningitidis infections. This patient avoided a catastrophic infection, due in large part to the prompt action of the ED in identifying the clinical features of meningococcemia and administering appropriate antibiotics. Ironically, it was the boy’s quick response to treatment that somewhat clouded the clinical picture by keeping him healthy-appearing throughout his hospital course.
The boy completed an uneventful course of antibiotics, and his close contacts were treated prophylactically. He was eventually discharged home with an excellent long-term prognosis.
For more information:
Emily Osier, MD, is a clinical research fellow in pediatric dermatology at Rady Children’s Hospital, San Diego. She can be reached at 8010 Frost St., Suite 602, San Diego, CA 92123; email: ejosier@gmail.com.
Andrew C. Krakowski, MD, is an attending physician at Rady Children’s Hospital, San Diego.
Disclosure: Osier and Krakowski report no relevant financial disclosures.