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Revisiting the History: Hypereosinophilia in a 4-Year-Old With Purpura.

A 4-year-old boy with developmental delay was admitted for evaluation of a new rash in the setting of leukocytosis and eosinophilia. The patient was healthy until 1 week before admission when he developed cough, congestion, and malaise. Upon presentation, he was on day 5 of amoxicillin, prescribed by an outside provider for unclear indications, but he took no other medications on a regular basis. The day before presentation, his mother noted “red, flat, pimple-like” lesions on his upper thighs that progressively spread down his legs and resembled “bruises.” At a local hospital, a complete blood count (CBC) demonstrated a white blood cell (WBC) count of 66 600/mm3. Although the patient was afebrile and non–toxic appearing, a blood culture was obtained, and he received intramuscular ceftriaxone due to the profound leukocytosis and concerns for possible infection. He was subsequently transferred to the emergency department of our hospital for further evaluation.

In the emergency department, vitals were notable for a pulse of 100 beats per minute, temperature of 35.2°C, respiratory rate of 32 breaths per minute, and oxygen saturation of 98% on room air and normal BMI for age. Physical examination was notable for a nontender, nonpruritic rash consisting of purpuric papules and macules of various stages of development on the bilateral lower extremities (Fig 1). He was otherwise well appearing with no joint or abdominal tenderness and no hepatosplenomegaly. Initial laboratories were notable for WBC count of 56 100/mm3 with 59% eosinophils and an absolute eosinophil count (AEC) of 33 100/mm3, a normal hematocrit of 37.2%, normal platelet count of 300 K/mcL, and normal coagulation markers. The patient was noted to have an elevated lactate dehydrogenase of 555 unit/L but normal uric acid level. A urinalysis obtained via a catheterized specimen was notable for trace protein and moderate blood; …