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Diffuse Erythematous Rash in a Child: A Journey to Diagnosis

An 11-year-old African American male with past medical history of attention deficit hyperactivity disorder on Vyvanse presented with 1 day of a diffuse erythematous rash in the month of October in western Tennessee. While at school, he suddenly developed fever, intermittent epigastric abdominal pain without radiation, lower back pain, and frontal headache. When he returned home from school, his mother noticed a diffuse erythematous rash over his entire body. He had some decreased oral intake but denied vomiting and diarrhea. His last bowel movement was approximately 1 week ago. There was no history of recent illness, trauma, or sick contacts. The patient had recently been on a camping trip but denied tick bites. The patient usually sleeps on the couch, and his mother had noticed spiders in the household. In the emergency department, he was found to be febrile, tachycardic, and tachypneic. A sepsis workup was completed including blood culture, urine culture, complete blood count, and C-reactive protein level, as well as a complete metabolic panel and rapid strep screen. He was admitted after receiving two 20 mL/kg normal saline boluses, intravenous ceftriaxone, and intravenous vancomycin. On admission, the patient was hesitant to move due to his abdominal pain. He remained febrile, tachycardic, tachypneic, and now mildly hypotensive (Figure 1). Physical examination revealed erythematous skin with tiny papules from head to toe. There was sparing of the palms and soles, an area of slight desquamation in the upper sternum measuring approximately 1.5 cm, and negative Nikolsky sign. The abdomen was soft with moderate tenderness and guarding near the umbilicus. There was also a 4 × 3 cm area of increased erythema and edema to the left of his umbilicus that was especially tender to palpation but without eschar, excoriation, or puncture (Figure 2). Finally, his left tympanic membrane was erythematous and bulging but without purulence. Laboratory findings were within normal limits except for a C-reactive protein of 59 mg/L and a mildly elevated total bilirubin at 1.3 mg/dL (Table 1). Abdominal imaging was obtained due to significant, localized umbilical tenderness and skin findings concerning for cellulitis versus intraabdominal abscess. Abdominal X-ray was within normal limits. Abdominal ultrasound did not show fluid collection or abscess formation. Given his systemic inflammatory response syndrome, our differential was broad including streptococcal scarlet fever, Stevens-Johnson syndrome, staphylococcal toxic shock syndrome, viral exanthem, and systemic loxoscelism (Table 2). We continued broad-spectrum antibiotics of vancomycin and ceftriaxone, and gave an additional fluid bolus for a total of 60 mL/kg since presentation to our emergency department.