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JAMA Pediatrics Clinical Challenge

Fever and Rash in a 7-Month-Old Infant

Image of figure 1


Sarah J. Adams, BSc
Mina Y. Kingsbery, MD
Sameera Husain, MD
Maria C. Garzon, MD

A previously well 7-month-old male infant presented to our emergency department with 1 week of loose stools, 4 days of fever up to 39.2°C, and 2 days of skin rash. His parents reported several pink papules that first appeared on his trunk and spread to his extremities within 24 hours. His increasing irritability and poor oral intake led to his admission for further evaluation. The patient's vaccinations were up to date. He had no history of perinatal infections, sick contacts, recent travel, or pets. The family lives in an apartment in New York City.

On physical examination, the patient had fewer than 20 pink papulovesicles, some with hemorrhagic crust, scattered on the upper chest, abdomen, lower back, and extremities (Figure, A and B). His palms, soles, and oropharynx were otherwise unremarkable.

Laboratory test results were notable for a mild leukopenia with a white blood cell count of 4.6 × 109/L (normal, 6.0-18.0 × 109/L) with 18% monocytes. C-reactive protein was slightly elevated at 3.38 mg/L (normal, <2.9 mg/L). He was started on treatment with intravenous ceftriaxone and intravenous acyclovir. Blood, urine, and wound cultures were taken, and a skin punch biopsy was performed (Figure, C).

See the full article for an explanation and discussion.

Author Affiliations: Adams, Kingsbery, and Husain are affiliated with the Department of Dermatology, Columbia University, New York, New York, and Garzon (mcg2@columbia.edu) is affiliated with the Department of Dermatology and Pediatrics, Columbia University, New York, New York.