Index of SuspicionCase 1: Pruritic, Erythematous, Papular, and Papulovesicular Rash in an 8-year-oldCase 2: Cough With Green Phlegm in an 8-year-oldCase 3: Polyarthritis, Raynaud Phenomenon, Hoarseness, Tapering Fingers, and Digital Ulcers in a 6-year-old

An 8-year-old boy presents with a 3-week history of red, itchy, raised lesions that developed vesicles and black crust. The lesions started on the neck and inguinal region but became generalized within a few days. He was diagnosed as having varicella and sent home with symptomatic management. A few days later, he was seen in the ED because of fever and persistence of the eruption. He was prescribed oral cephalexin for a possible secondary infection of the varicella. He has not improved and is finally admitted to a regional hospital for further evaluation. Physical examination shows a generalized eruption of erythematous papules, most of which have a dark crust in the center, as well as a few papulovesicles on the extremities, including the palms and soles (Fig. 1). He has enlarged inguinal nodes and complains of intense pruritus. The differential diagnosis includes varicella, herpesvirus infection, and vasculitis. Figure 1. Eruption consisting of erythematous papules, most of which have a dark crust in the center, and a few papulovesicles on the right lower extremity. Results of laboratory studies include: Urinalysis is negative for protein and erythrocytes and a urine culture is sterile. Results of bacterial culture and polymerase chain reaction testing for herpes group viruses from the skin lesions are negative. Additional evaluation leads to the diagnosis. An 8-year-old boy who has a history of recurrent pneumonia, CHARGE association, repaired tetralogy …