Fever and a Multifocal, Erythematous, Nodular Rash in an 18-month-old Boy

Abstract

1. Angelique E. Boutzoukas, MD* 2. Jared Kusma, MD* 3. Joshua R. Watson, MD† 4. Bonita Fung, MD‡ 5. Christopher P. Ouellette, MD†,§ 1. *Pediatric Residency Program, 2. †Division of Infectious Diseases, 3. ‡Department of Anatomic Pathology and Laboratory Medicine, and 4. §Host Defense Program, Nationwide Children’s Hospital, Columbus, OH A previously healthy 18-month-old boy presents to the emergency department after 6 days of cough, rhinorrhea, daily fever, irritability, and progressive rash with extremity swelling. On admission, he is febrile to 38.2°C and ill-appearing. Physical examination is notable for lip and tongue erythema, a sandpaper-like exanthem on his back and extremities with scattered petechiae, and tense bilateral hand and feet edema and erythema. In addition, multiple erythematous, tender, indurated, nodular lesions (2 to 3 cm in diameter) are present on the chest, abdomen, right arm, and left hand (Fig 1). Figure 1. Numerous, tender erythematous nodular lesions localized to chest and abdomen. Laboratory evaluation is notable for leukocytosis (white blood cell count of 40,000/mm3 [40 × 109/L] with 49% segmented neutrophils, 41% band forms) and an elevated erythrocyte sedimentation rate (103 mm/hour), C-reactive protein (25.9 mg/dL [2,466.7 nmol/L]), aspartate aminotransferase (63 U/L [1.05 ukat/L]), and alanine aminotransferase (46 U/L [0.77 ukat/L]). Urinalysis shows evidence of pyuria (18 white blood cell/high power field) and proteinuria (100 mg/dL). A blood culture is obtained, and intravenous clindamycin 10 mg/kg every 8 hours is initiated to target typical skin organisms. Given the unusual nodular rash, dermatology is consulted and performs a skin biopsy of a nodule on the abdomen. Blood culture results reveal the first clue, and histopathologic analysis of the skin biopsy reveals the diagnosis. Given the initial presentation, he was hospitalized with an initial differential diagnosis including Kawasaki disease (KD), toxic shock syndrome (TSS), a serum sickness-like reaction, native valve infective endocarditis with cutaneous emboli, …