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Fever and Papular-purpuric Exanthema in a 7-year-old Boy

Arias-Vivas, Eva MD*; Illán-Ramos, Marta MD*; Campos, Lucía MD; Pérez-Rodríguez, Olga MD*; Culebras, Esther MD, PhD; Ramos-Amador, José Tomás MD, PhD*

The Pediatric Infectious Disease Journal: December 2019 - Volume 38 - Issue 12 - p 1254
doi: 10.1097/INF.0000000000002465
Your Diagnosis, Please

From the Departments of *Pediatrics


Microbiology, Hospital Clínico San Carlos, Madrid, Spain.

Accepted for publication August 5, 2019.

The authors have no funding or conflicts of interest to disclose.

Address for correspondence: Marta Illán-Ramos, MD, Department of Pediatrics, Hospital Clínico San Carlos, C/Profesor Martín Lagos, s/n. 6° floor, 28040 Madrid, Spain. E-mail:

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A previously healthy 7-year-old boy presented to the emergency department (ED) in winter because of pruritic exanthema on the distal areas of his upper and lower extremities and fever up to 38.5°C for 1 day.

He was born in Spain to a family of Moroccan origin and had no travel history. He had no known allergies, was fully immunized, and had no known contact with animals, new foods or detergents. His parents and siblings were healthy.

On admission to the ED, the patient had a temperature of 37.9°C, blood pressure of 125/87 mm Hg and heart rate of 157 beats/min. Physical examination was notable for a symmetric maculopapular and petechial rash primarily involving the distal extremities, including the hands and feet. There were also purpuric lesions in the oral cavity (Fig. 1). He had no lymphadenopathy or meningeal signs. The remainder of his examination, including cardiac and neurologic systems, was normal.



Laboratory testing revealed a white blood cell count of 8200/µL (51% neutrophils, 45.1% lymphocytes, 2.1% monocytes, 1.6% eosinophils, 0.1% basophils), platelet count of 81,000/µL, C-reactive protein of 1.8 mg/dL and procalcitonin of 1.16 ng/mL. Coagulation studies were mildly abnormal, including the international normalized ratio of 1.3 and prothrombin activity of 66%. The rest of his laboratory parameters (hemoglobin, hematocrit, urea, creatinine, electrolytes and glucose) were normal. Pharyngeal swab for detection of group A streptococcus, blood cultures and serologic testing (IgM and IgG) for parvovirus B19, Epstein-Barr virus and Toxoplasma gondii were all negative.

The patient was admitted to the hospital. Additional testing revealed the diagnosis.

For Denouement see P. 1255.

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