A FEBRILE 10-year-old girl was referred for evaluation of a diffuse febrile papulovesicular eruption present for 5 days consisting of rare sparse vesicles with a tiny erythematous halo and some papules on the trunk and legs with mild itching (Figure 1 and Figure 2). Her temperature had fluctuated between 38°C and 40°C, and on the third day, the family pediatrician began acyclovir treatment (800 mg, 5 times daily) for suspected varicella infection, which she had had 4 years prior. The cutaneous lesions increased in number and size, some showing central necrosis. Her history was otherwise unremarkable. Few cutaneous lesions were present on the head; the palms of her hands, soles of her feet, and mucous membranes were spared.
Findings from laboratory examinations included a high white blood cell count (12.7 × 109/L) with increased neutrophils (8.3 × 109/L), normal values for circulating lymphocytes (2.2 × 109/L) and eosinophils (1.0 × 109/L), and a slight increase erythrocyte sedimentation rate (28 mm/h). Levels for serum immunoglobulin and circulating immunocomplex were normal. Findings from biochemical examination, antinuclear antibody tests, and Waaler Rose test were negative. Findings from hepatitis A, B, and C panels and toxoplasma antibodies were negative. Epstein-Barr virus titers showed positivity only for IgG and Epstein-Barr nuclear antigen, while titers for IgM were negative. Urinalysis showed mild microhematuria and proteinuria. Results of viral, fungal, and bacterial cultures from the vesicles and pustules as well as blood cultures were negative. A skin punch biopsy of 4 mm was obtained from a papular lesion (Figure 3). Antipyretic therapy was administered. Seven days after admission her temperature gradually decreased, and the lesions disappeared after another 7 days with mild residual hypopigmented scars. No recurrences were observed at 1-year follow-up.
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