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Morning Report: Melissa Kleschen, MD, PGY3

A 13-month old previously healthy child presented with a 3 day fever up to 102.5F, vomiting, and a rash on his right hand described as red dots. On exam, he had tachycardia, petechiae on his right wrist extending up his arm, and multiple erythematous lesions on his back and leg. Labs showed a normal urinalysis and elevated white blood cell count. The leading differential diagnosis was a viral infection like enterovirus or echovirus given the presentation of fever and petechiae. Treatment included antibiotics and fever reducers. The rash spread slightly but symptoms resolved within 3 days without growth from cultures.

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Emily Eresuma
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534 views14 pages

Morning Report: Melissa Kleschen, MD, PGY3

A 13-month old previously healthy child presented with a 3 day fever up to 102.5F, vomiting, and a rash on his right hand described as red dots. On exam, he had tachycardia, petechiae on his right wrist extending up his arm, and multiple erythematous lesions on his back and leg. Labs showed a normal urinalysis and elevated white blood cell count. The leading differential diagnosis was a viral infection like enterovirus or echovirus given the presentation of fever and petechiae. Treatment included antibiotics and fever reducers. The rash spread slightly but symptoms resolved within 3 days without growth from cultures.

Uploaded by

Emily Eresuma
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Morning Report

Melissa Kleschen, MD, PGY3

Case Presentation
HPI:
Previously healthy 13 month old who presents with

a 3 day history of fever to 102.5 F. No cough or congestion. 2 episodes of non-bloody, non-bilious emesis, only with po intake. No diarrhea. Refusing to solid food, is taking good liquids. Normal UOP. Has a rash that began today on his right hand. The rash is described as red dots. Not itchy. Since sitting in clinic, developing lesions on back and chest.

PMH/ PSH:
Repaired pyloric stenosis as infant, no complications. No history of UTI No history of recurrent infections

MEDICATIONS: None ALLERGIES: NKDA

IMMUNIZATIONS: Up to date
DEVELOPMENT: Normal FAMILY HISTORY: No childhood or congenital

illnesses. SOCIAL HISTORY: In clinic with mother, grandmother, and 4yo sister. No known sick contacts. Sister dose go to preschool.

Exam
Wt 11.8 kg (78%), T 102.7, HR 170, RR 28, Sat

99% on room air General: well appearing and non-toxic, but crying. Somewhat consoled with grandmother. Alert, interactive, refusing exam. Head and Neck:
Eyes: normal, no conjunctival injection Bilateral TMs: pearly grey O/P: normal mucosa erythema present, but no

exudate or ulceration. Nose: normal nasal mucosa - no congestion Neck: supple, no adenopathy, full ROM

Chest: clear to auscultation, no wheeze or crackles,

no increased WOB Heart: Tachycardic, regular rhythym, S1 and S2 normal, no murmur Abdomen: Soft, non-tender, no hepatosplenomegaly, non-distended. Healed scar present. Extremities: Cap refill 3 seconds. No edema. Skin: ~10 pinpoint non-blanching purple petechiae on right wrist extending up arm. There are multiple pinpoint erythematous lesions on his back and left LE, but these do blanch.

Differential diagnosis???
13 month old who presents with fever and

petechiae.

Labs/Imaging
UA: SG >1.030, negative for blood, nitrite, and

leuk esterase CBC: WBC 10 (29% lymp, 46% neut), HGB 12, HCT 34.8, PLT 240. Rapid strep negative Cultures of blood and urine sent

Follow Up
In clinic, given:
Ibuprofen, Tylenol Rocephin IV

Repeat exam without tachycardia, fever, and infant

less fussy. No spread of petechiae. Saw PCP next afternoon and had some spread of rash. Throat more erythematous. Fevers had stopped. Family members developed pharyngitis the following day. Symptoms resolved within 3 days. No growth from blood, urine, or strep cultures.

Enterovirus Infections
Person to person through fecal/oral contact-

Multiple enteroviruses:
Polio Coxsackievirus Echovirus Enterovirus

90% are asymptomatic or mild febrile illness only

Viral Exanthems
Maculopapular eruptions
Especially echovirus. Nonspecific rash, minimal distress to patient. Accompanied with fever for 24-36 hours.

Viral Exanthems/Enanthems
Hand, Foot, Mouth Disease
Fever, oral vesicles, peripheral cutaneous lesions

on hands, feet, buttocks Can also have onychomadesis (separation of nail plate from nail bed) Incubation of 3-5 days Illness usually lasts 2-3 days Coxsackievirus A16, B1-5 Echovirus 4-6

Viral Exanthems/Enanthems
Herpangina
Vesicular enanthem of tonsils and soft palate Can be accompanied by fever and odynophagia

Viral Exanthems/Enanthems
Petechiae and purpura:
Most likley echovirus and coxsackievirus. Other causes: Trauma: usually over extensor surfaces of LE, bony prominences, forehead Purpura Fulminas: Neisseria meningitidis, varicella, GAS, strep pneumoniae. Usually ill-appearing. The purpura can be followed by black/blue hemorhagic necrosis. HSP: On buttocks and LE. Also have arthritis, abdominal pain, nephritis Drug induced: antibiotics. Can be 7-21 days after starting drug Vitamin C deficiency, Ehlers-Danlos, Thrombocytopnia, ITP, HUS, DIC, Inherited or acquired platelet function, Clotting factor deficiencies, Hemophilia, Vitamin K deficiency, Liver disease

References
UpToDate: Enteroviral Infection and Evaluation of

Purpura in Children. Zaoutis T, Klein J. Enterovius Infections. Pediatrics in Review. 1998; 19: 183. American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.

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