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Abdominal discomfort, sore throat, painful skin lesions in a 6-year-old female
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A previously healthy 6-year-old female had a minor illness with fever and upper respiratory tract infection symptoms about a week ago that lasted 1 day. Then, for the following 2 to 3 days, she felt well. However, she began feeling sick again with subjective fever, abdominal discomfort and sore throat with the appearance of some mildly painful skin lesions. Her throat was described to be red with white exudate by her mother, along with some painful erythema of her vaginal mucosa as well. Because she seemed to be getting worse, without a confident diagnosis, the next day she was admitted to the hospital for evaluation.
She is a normal first-grade student and further history revealed contact with a classmate who was recently sent home with “total body impetigo,” but knew of no other sick contacts. She has had no travel or unusual animal contact, and her immunizations are up to date, with none given in recent months. A detailed history of toxin exposure was negative, and no medications have been given.
Exam on admission revealed normal vital signs, and the findings noted above in the history and shown (Figures 1-3). The rest of her examination was completely normal. Admitting lab tests include a normal CBC, normal comprehensive metabolic panel, mildly elevated C-reactive protein level, and a normal cath UA; however, the respiratory virus PCR panel was positive for rhinovirus/enterovirus, reported together due to cross reactivity of the genetic target that cannot be distinguished by this panel. The other viruses in the panel — including adenovirus, respiratory syncytial virus, influenza, parainfluenza and human metapneumovirus — along with a rapid streptococcal screen were all negative. Additional tests included Mycoplasma and Epstein-Barr virus titers, both of which were negative.
Figure 1. The throat appeared red with white exudate.
Figure 2. Appearance of mildly painful skin lesions.
Figure 3. Painful erythema of vaginal mucosa.
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Case Discussion
Our initial impression with the information provided was atypical hand-foot-and-mouth syndrome (A); upon follow-up, this was still the only good choice, as all the other tests were negative as well as the recognition of unusual cases of hand-foot-and-mouth syndrome in the last few years due to coxsackievirus A6 (CVA6). Since she had no respiratory symptoms consistent with a rhinovirus infection, we took the Respiratory Viral Panel result to be enterovirus positive, and surmised that it was likely CVA6.
Atypical Stevens-Johnson syndrome was featured in the September 2014 “What’s Your Diagnosis?” column. This unusual condition has been most commonly associated with Mycoplasma pneumoniae infections, and differs from common Stevens-Johnson syndrome in that there is little to no skin involvement, similar to the patient presented. The features mitigating against this diagnosis in the case presented were the positive enterovirus PCR and negative Mycoplasma titers. Otherwise, if there were supporting lab results, this could be consistent with atypical Stevens-Johnson syndrome.
We could have sent the specimen to a reference lab for specific identification, but that would have driven the cost up, and would not have changed our management. An example of the unusual appearance of similar cases we have had over the last couple of years is shown (Figures 4-5).
Figure 4.
Source: Brien JH
Figure 5.
Source: Brien JH
Epstein-Barr virus (EBV) mononucleosis can certainly cause an exudative tonsillitis, but the unusual skin lesions and vaginal mucositis would not fit. Then, with the negative EBV titers, mononucleosis can probably be taken off the list. The same could be said about group A streptococcal tonsillitis with a rash. Group A Streptococcus is easy to recover by rapid testing or culture; if there is a rash, it is likely to be associated with scarlet fever, in which case, it is a fine papular (scarlatiniform) rash, unless it is a case of group A streptococcal toxic shock, which can produce a diffuse erythroderma.
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- James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He also is a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Brien reports no relevant financial disclosures.