Visual Diagnosis: High Fever, Maculopapular Rash, Perianal Desquamation, and Conjunctivitis in a 3-year-old Boy.

Abstract

1. Alexander K.C. Leung, MD* 2. Consolato Maria Sergi, MD† 3. Kin Fon Leong, MD‡ 4. Paul F. Kantor 5. MD§ 1. *Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada 2. †Departments of Pediatrics, Laboratory Medicine, and Pathology, University of Alberta, Edmonton, Alberta, Canada 3. ‡Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia 4. §Division of Cardiology, Department of Pediatrics, University of Southern California, Los Angeles, CA A 3-year-old Chinese boy presents with high spiking fevers of 5 days' duration despite treatment with acetaminophen. He has cracked red lips, a widespread maculopapular rash, and bilateral nonpurulent conjunctival injection. There is no history of joint pain, vomiting, abdominal pain, or diarrhea. The medical history is otherwise normal. On examination the child is irritable. His temperature is 103.6°F (39.8°C), heart rate is 102 beats/min, respiratory rate is 27 breaths/min, and blood pressure is 95/60 mm Hg. He has a generalized blanching polymorphous maculopapular rash (Fig 1). The lips are cracked and erythematous. The bulbar conjunctiva is injected bilaterally with sparing of the limbus and without exudate. The tongue is strawberrylike. Perianal erythema and desquamation are noted (Fig 2). Marked erythema is noted on the lateral aspect of the left upper arm surrounding a previous Bacillus Calmette-Guerin (BCG) inoculation site (Fig 3). The hands and feet are erythematous and edematous (Figs 4 and 5). A sharp demarcation with an abrupt change to normal skin is noted at the wrists and ankles (Figs 4 and 5). A tender, nonfluctuant, freely mobile lymph node measuring 2×3 cm is palpable in the left anterior cervical area. The remaining examination findings are normal. Figure 1. A maculopapular rash over the trunk. Also noted in the picture are cracked red lips. Figure 2. Characteristic perianal desquamation. Figure 3. Erythema is surrounding a Bacillus Calmette-Guerin inoculation site. Figure 4. Erythema and indurated edema of the right foot. Figure 5. Erythema and indurated edema of the left hand. Note the sharp demarcation with an abrupt change to healthy skin. Laboratory findings are as follows: white blood cell count, …