A Widespread Pruritic Rash With Facial Swelling and Black Streaks.

Abstract

A healthy girl aged 4 years presented with a 5-day history of a pruritic rash on her arms, neck, axillae, and face. The rash started as small pink bumps on her arms that spread to involve the axillae, neck, and upper chest. Four days prior to arrival, she developed significant rednessandpruritusofher face.Onarrival, herparentsnotedblack streaksonher right arm,promptinganurgentemergencydepartmentevaluation. Treatmentprior topresentation includeddiphenhydramine, cetirizine, and a 20-mg dose of prednisone without improvement. The patient was otherwise healthy with normal development and growth. She had a history of mild atopic dermatitis and was not taking any medications. She had no known history of drug allergy or contact allergy. The patient livedwith her 2 siblings and both parents, whowere all asymptomatic. She had no pets and no recent travel, and her vaccinations were up to date. Onphysical examination, the patientwas actively scratching the involved skin. The bilateral arms, axillae, anterior neck, and facehadpoorlydefined, blanchingpink-redpatches andedematousplaqueswithout epidermal change (Figure, A). Jet black,well-defined, and slightly shiny linear streakswithperipheral erythemawerenotedonher right forearm,with smaller circular, black macules on the ipsilateral biceps and axilla (Figure, B). Quiz at jamapediatrics.com A