Visual Diagnosis: A Child Who Has Acute Onset of Unusual Skin Lesions and Edema

1. Ceyda Acun, MD* 2. Gonca Ustundag, MD* 3. Ayhan Sogut, MD* 4. Rafet Koca, MD† 5. Gamze Numanoglu, MD‡ 1. *Department of Pediatrics 2. †Department of Dermatology 3. ‡Department of Pathology, Karaelmas University, School of Medicine, Zonguldak, Turkey A 13-month-old boy presents to the emergency department with a 1-day history of rash on his face, medial thighs, and upper trunk and swelling of his face, ears, hands, and feet. He has a 3-day history of an upper respiratory tract infection. There is no recent history of immunization or drug intake. The physical examination reveals an alert child who has a widespread rash over his peroral area, chin, cheeks, and ears, with sparing of the mucous membranes (Figs. 1, 2). His vital signs are appropriate for his age. The rash appears in a rosette pattern of 1 to 2-cm diameter, purplish-red, slightly raised macules. A milder rash appears on his medial thighs and upper trunk. Both his face and ears are significantly swollen, and the flexor surfaces of the hands and feet are mildly swollen. The patient is admitted for observation and evaluation. Figure 1. Purplish-red, slightly raised macules on the face and trunk. Figure 2. Purplish-red, slightly raised macules on the face and ear. Over the next 3 days, the rash spreads to his arms and legs (Figs. 3, 4). However, apart from a transient mild fever, the child appears well, having no obvious systemic symptoms. Figure 3. Rash over extremities. Figure 4. Rash over legs and buttocks. The laboratory examination reveals a normal complete blood count, serum immunoglobulins, C3 and C4 levels, circulating immune complexes, antistreptolysin titers, coagulation studies, urinalysis, renal …