RT Journal
A1 Burnham JM, Kreiger PA, Paessler M, Kersun LS, Cron RQ
T1 PIcture of the month—quiz case
JF Archives of Pediatrics & Adolescent Medicine
JO Archives of Pediatrics & Adolescent Medicine
YR 2006
FD November 1
VO 160
IS 11
SP 1177
OP 1177
DO 10.1001/archpedi.160.11.1177
UL http://dx.doi.org/10.1001/archpedi.160.11.1177
AB 
On hospital admission, he was ill appearing and febrile (40°C), with marked oral ulceration. 
In addition to an eschar measuring 1.5 cm on his left upper arm with underlying induration (Figure 1), he had a tender lymph node in the nearby axilla. His laboratory test results showed a white blood cell count of 1.6 × 103/μL (12% band forms, 67% segmented neutrophils, 20% lymphocytes), a hemoglobin concentration of 9.4 g/dL, and a platelet count of 71 × 103/μL. His fibrin split products were elevated and the fibrinogen level was falling. His serum ferritin level was 18 070 ng/mL (40 603 pmol/L). His C-reactive protein level was elevated at greater than 20 mg/dL, but surprisingly, his erythrocyte sedimentation rate was normal at 5 mm/h. His serum and urine electrolyte levels were consistent with syndrome-inappropriate antidiuretic hormone, and his uric acid and lactate dehydrogenase levels were elevated. Epstein-Barr virus testing was consistent with prior infection.