Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 4-year-old female with no significant past medical history presents to the ED with a rash. The rash was noticed three days ago and has remained the same. It is pruritic but not painful. The rash started on her face and then spread to her arms and legs.  No new known environmental, chemical or possible toxic exposures and this is the first time she has had a rash before. No relief with Benadryl. Shots up to date.

ROS: Associated symptoms include congestion, cough and coryza.  No fevers, wheezing, abdominal pain, vomiting, or diarrhea.  Decreased urinary output was noted by her parents.

Vital Signs: T 99.3, HR 128, RR 26, BP 104/62, SpO2 99% on RA

Pertinent physical exam: Patient is a happy appearing, playful, interactive child. TM’s are clear. Oropharynx is moist without lesions or exudate. Neck is supple. Heart sounds are normal. Faint, end expiratory wheezing appreciated on lung auscultation. Abdomen soft, non-tender. Diffuse, papular lesions noted throughout, most prominently on the extremities and cheeks. They do not appear painful and do not blanch with digital pressure. A few lesions have surrounding erythema. No vesicles. The rash was noted on his hands, but not on the feet or mucous membranes. No other pertinent exam findings.

What’s the diagnosis?

What is this?

Well, in a nutshell it’s a specific viral exanthem that got itself a name. Here are some quick facts:

• Symmetric eruption with an acral distribution (extensor surfaces, hands, feet, buttocks, cheeks). It is papular or papularvesicular in nature, with some lesions coalescing into plaques.
• Typically seen in children less than five.
• Usually preceded by either a GI or upper respiratory infection with a viral etiology, however, with the most common causes including Hepatits B (HBV) or EBV infection.
• This may in fact be the only clinical manifestation of an acute HBV infection.
• Associated symptoms typically include malaise, diarrhea and low grade fever. 
• Lymphadenopathy is often present on physical exam.
• The rash will typically progress during the first two to three weeks, and can last days to months before spontaneous remission.
• If the patient is at risk for HBV (not vaccinated, immunocompromised, etc), further workup should include liver function tests and hepatitis B serology.
• The differential can be broad and include entities such as Fifth’s Disease, erythema multiforme, hand foot and mouth disease, and scabies.

How do I treat this?

• For mild cases, moisturizer creams or calamine lotion for the pruritis can be helpful.
• For more severe cases, consider oral antihistamines or hydrocortisone cream.

Case Conclusion:

The patient was prescribed hydrocortisone cream as needed for pruritis, and was provided with pediatric dermatology follow up.

References:

Chuh, Antonio. Gianotti-Crosti Syndrome. UptoDate. <www.uptodate.com>. 2016.

The contents of this case were deliberately altered to protect the identity of the patient. All content in this report are for educational purposes only.

Faculty Reviewer: Drs. Chris Merritt and Alyson McGregor

See you again soon!