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OVER 5 days, a previously healthy 13-year-old girl developed fever, bilateral conjunctival injection, difficulty swallowing, swollen knees, and a petechial rash. Physical examination showed her lips to be swollen and red, her throat red with a pharyngeal ulcer, and small vesicular lesions at the base of the tongue and on the buccal mucosa of the left cheek (Figure 1). Her conjunctivae were injected. Both knee joints were swollen and mildly tender to motion and palpation. A discrete petechial rash was present on the legs below the knees, including the dorsum and plantar surfaces of the feet and on the forearms, and palms of both hands (Figure 2 and Figure 3). The fingers of both hands were swollen.

The white blood cell count was 2.4 ×10⁹/L (reference range, 4.5-11.0 ×10⁹/L) and differential cell count of 0.69 polymorphonuclear cells, 0.15 band forms, 0.11 lymphocytes, and 0.5 monocytes. The hemoglobin was 132 g/L (reference range, 120-150 g/L), and a platelet count of 82 ×10⁹/L (reference range, 150-450 ×10⁹/L).