Visual Diagnosis: A 5-year-old Male Who Has an Intensely Pruritic Maculopapular Rash

Abstract

1. Saad Siddiqui, MD* 2. Vimal Master Sanker Raj, MD* 3. Arthur N. Feinberg, MD* 1. *College of Human Medicine, Michigan State University, Kalamazoo Center for Medical Studies, Kalamazoo, Mich A 5-year-old boy presents to the clinic having a 3-day history of rash and itching. The rash started in the periumbilical area and spread to both sides of the groin. The child has severe pruritus causing persistent crying and inability to sleep at night. There is no history of fever or systemic symptoms. No other family members are affected. Of note, the family recently went on a summer camping trip in northern Michigan. The child's general health has been good; he has no documented allergies and is receiving no medication. However, the family expressed concern about allergies (rhinitis) during the last health supervision visit and mentioned that there are several pets in the home. There is no known exposure to farm animals or grain. Physical examination reveals a red, maculopapular rash clustered in the periumbilical area (Fig. 1), with spread to the groin. Another lesion is in a finger web and a third in a toe web. There is no bleeding, excoriation, infection, or burrowing. There is no involvement of the face or buttocks. A clinical diagnosis is made. Figure 1. Erythematous, maculopapular rash clustered on trunk and periumbilical region. The clinical diagnosis was based on the physical findings of typical skin allergic/inflammatory reactions with absent burrowing on unexposed areas of the skin plus the history of outdoor exposure during warmer months. Ultimately, the patient's rapid recovery helped confirm the initial impression. ### Discussion There is little mention of chigger bites in standard pediatric textbooks. This case illustrates how to identify, treat, and prevent chigger bites. Pruritic skin rashes usually evoke consideration of eczema or urticaria. If insect bites are suspected, the clinician typically searches for an area of entry (punctum), but papular urticaria at the initial insect bite site may recur without puncta for months in the same areas. The phylum Arthropoda , …