Petechial Rash With Pandemic Influenza (H1N1) Infection

Abstract

To the Editors: Acute fever and petechial rash in children pose a challenge for the pediatrician, because up to 20% of them will have serious bacterial infection.1 Influenza virus is not a common cause of rash, and a rare cause of petechial rash.1,2 Of 100 pediatric cases of pandemic influenza H1N1 admitted to our hospital from August until December 2009, we had 3 children, who presented in December 2009 with high fever, petechial rash, and rhinorrhea. All were treated for suspected meningococcal infection, but were proven to have novel influenza H1N1 by PCR, and negative blood cultures. They were discharged in a good clinical condition. The first child was an 18-month-old girl with high fever, cough, rhinorrhea, and loose stools. On admission she was well appearing and had a maculopapular rash over her chest with few petechial lesions. Because of her high fever and petechial rash (inspite of her well appearance), she was admitted and treated with ceftriaxone after blood cultures were taken. The next day a PCR for influenza H1N1 was positive, and after 2 days she was discharged with no additional treatment in a good medical condition. The other 2 children were about the same age and had similar histories and examinations. One of them was ill appearing, and both received antibiotics and antiviral therapy; they were well after few days. All 3 of them had normal platelet count, and all had positive PCR for H1N1 and blood cultures were sterile. The type of illness caused by influenza A virus infection depends on the age of the host. Most children younger than 5 years of age have fever and signs of upper respiratory tract involvement. Older children and adults have fever, chills, headache, sore throat, myalgia anorexia, and dry cough.2 Rash is not a common manifestation of influenza and petechial rash, simulating meningococcal infection, is rare.1,2 There are some reports of novel influenza H1N1, presented with rash,3–5 but it was uncommon, and there was no description of the rash in those articles, except for one case with a maculopapular rash.3 Children often present in the summer and fall with fever and petechial rash associated with enteroviral infection, but in other seasons it is not very common, raising the possibility of serious bacterial infection. Our 3 cases, in face of the current pandemic, illustrate the need to search for other viral and possible bacterial infections in a child with fever and petechial rash. Yael Shachor-Meyouhas, MD Imad Kassis, MD Pediatric Infectious Diseases Unit Meyer Children's Hospital Rambam Health Care Campus Haifa, Israel