Visual Diagnosis

Abstract

1. Donald H. Arnold, MD, MPH* 2. David M. Spiro, MD, MPH† 1. *Departments of Emergency Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn 2. †Departments of Emergency Medicine and Pediatrics, Oregon Health and Science University, Portland, Ore A 5-year-old girl who has a history of eczema and seasonal allergic rhinitis presents to the pediatric emergency department with the complaints of an enlarging rash and right-sided facial weakness. The patient was seen by her pediatrician 5 days ago and was diagnosed with a flulike illness. Her pediatrician recommended ibuprofen for relief of her symptoms. Two days ago, her mother noticed a rash on the girl's right leg that has expanded in size. On awakening this morning, she was unable to move the right side of her face. No other family members are ill. Physical examination reveals a well-appearing child in no acute distress. Her weight is normal for age, and vital signs are within normal limits. Facial asymmetry is evident, with right-sided facial weakness and a droop in the right corner of her mouth (Figure⇓). She cannot wrinkle her forehead or close her eye completely on the affected side. There is no nuchal rigidity, and Kernig and Brudzinkski signs are normal. A 5-cm round, symmetric, blanching erythematous rash with central clearing that is slightly warm is apparent on her right anterior thigh. There are no other rashes, and the remainder of the physical examination findings are normal. A brief video of her general examination is provided (Click for Video) . Figure. Right-sided facial weakness. A complete blood count demonstrates a hematocrit of 38% (0.38) and a white blood cell count of 5.6×103/mcL (5.6×109/L) with 45% neutrophils, 27% lymphocytes, and 14% monocytes. The platelet count is 274×103/mcL (274×109/L). Serum electrolyte, alanine transaminase, and aspartate transaminase values are normal. The erythrocyte sedimentation rate is 24 mm/hr. Additional serum testing further supports the diagnosis after consideration of the child's environmental exposures and season of year. ### Lyme Disease With Erythema Migrans and Bell Palsy An enzyme-linked immunosorbent assay (ELISA) for Borrelia burgdorferi …