Fever and cutaneous lesions in a 2-year-old toddler: More than skin deep?

March 1, 2007

It is early evening when a previously healthy 2-year-old Hispanic girl is brought to the hospital by her mother. The girl has a history of fever to 100.2 F axillary, and skin lesions that began four days earlier. The skin lesions are described as following a progressive course. The lesions would begin as non-itchy red patches with a central vesicle that would burst, leaving an ulcer with a black base.

DR. BROSNAN is an emergency medicine resident, University of California, Irvine.

DR. LE-BUCKLIN is pediatric residency director, University of California, Irvine.

DR. ADLER-SHOHET is assistant director of pediatric infectious diseases, Miller Children's Hospital, Long Beach, Calif.

The authors and section editor have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.

It is early evening when a previously healthy 2-year-oldHispanic girl is brought to the hospital by her mother. The girl has a historyof fever to 100.2° F axillary, and skin lesions that began four days earlier.The skin lesions are described as following a progressive course. The lesionswould begin as non-itchy red patches with a central vesicle that wouldburst, leaving an ulcer with a black base.

The mother reports that the patient had one episode of non-bilious, non-bloody emesis three days prior to admission. She has a five-day history of mild cough with nasal congestion as well as a history of decreased appetite. Parents deny diarrhea, dysuria, or oliguria.

The patient is using Mentrolat (Mexican antiseptic topical ointment) on her wounds and acetaminophen (Tylenol) for fever. She has no known allergies. Her immunizations are up-to-date. Her past medical, birth, and developmental histories are unremarkable.

The patient's family history is notable only for her brother, who has pervasive developmental delay, and both parents, who suffer from Type 2 diabetes mellitus.

The patient lives with both of her parents as well as her brother. She was born in the US, and her parents were born in Mexico. No smokers or pets live in the house. The patient does not attend daycare, there is no history of recent travel, and she otherwise has not had exposure to ill contacts.

From the outside

Looking in

You decide to do a set of initial labs. Findings include a complete blood count with a white blood cell count of 2700/mm3 (10% neutrophils, 18% bands, 56% lymphocytes, 12% atypical lymphocytes, and 4% monocytes)-absolute neutrophil count was 756. The patient's hemoglobin level is 8.8 g/dL and her hematocrit is 26.4%; the platelet count is 171×103 platelets/mm3 . Serum electrolytes, blood urea nitrogen, and creatinine levels are within normal range, as is her reticulocyte count. Albumin is found to be decreased (1.6 g/dL), while her uric acid is elevated (7.5 g/dL). Wound and blood cultures are also obtained.