Meet little Jimmy. No, this isn’t his real name. Jimmy has been relatively healthy for his 17 months of life. Eating and drinking has been great. No recent diarrhea or vomiting; however, Mom became worried when she noticed a rash. Yes, I said it….a rash. Initially it began as a few bumps that started to spread along his arms and legs. Sounds a little strange, eh? Here’s more background…

Let’s go back about 6 weeks prior to me seeing little Jimmy in the pediatric ED. He was prescribed Amoxicillin for otitis media. It’s a standard medication that’s given; however, he began to develop this rash around that time. No other associated symptoms though. Not pruritic and did not seem to bother him. Intermittent tactile fevers, but Mom did not associate the rash and fever. Thinking the antibiotic was the culprit, she saw the Pediatrician who said to stop taking the medication [Amoxicillin]. Pediatrician thought this could be a drug reaction.. Little Jimmy was given some OraPred and Benadryl. Told to follow up in the next several days…

Rash begins to improve over the next week or so; however, a week prior to coming to the ED, the rash returns. This time, the rash is all over the body: face, arms, legs, torso, diaper area. Continues to have the intermittent tactile fevers but the child overall seems relatively well. By this time, Mom is fed up. She’s seen the Pediatrician multiple times and has not gotten a definite answer about the rash’s etiology.

Oh yea… Mom is on a deadline too. She’s moving across the country in 1 week and NEEDS an answer.
What’s that? Describe the rash.. oh yea!

Vitals: Stable, Afebrile
General: Child is mildly fussy but consolable on examination.

Skin: Diffuse, erythematous rash along bilateral upper and lower extremities.
Scattered vesicles with occasional patches throughout extremities, most noted to the legs.
Diaper area appears erythematous, however no vesicles.
When looking at the face, a peri-oral rash is present consisting of crusted, opened vesicles. Crusting is a yellowish-golden color.

Yellowish-golden crust ….. Impetigo?
Vesicular rash along extremties with patches ….. Eczema herpeticum?
Periorificial rash affecting both mouth and diaper areae ….. Acrodermatitis enterohepathica?

Impetigo:
Causative agent(s): Staphylococci and Streptococci
Appearance: Erythematous sores that can rupture, releasing fluid or pus, and covered by a yellowish-golden crust
Treatment: Topical cream vs Systemic antibiotic treatment [Penicillins, 1st gen Cephalosporins, Doxycycline, Clindamycine]

Eczema herpeticum:
Causative agent (s): Herpes Simplex Virus, both 1 and 2, Coxsackievirus.
Appearance: Vesicles superimposed on healing atopic dermatitis
Commonly associated s/s: Fever, Lymphadenopathy
Treatment: Supportive Care, Antiviral therapy [Acyclovir]

Acrodermatitis enterohepathica
Appearance: Erythematous plaques that can evolve into vesicles and bullae
Pathophysiology: Autosomal recessive; Zinc deficiency
Treatment: Supportive care, Zinc supplementation

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We see many rashes in the ED. Not all of them are “Viral Exanthems.” All of the mentioned “rashes” can be treated. It’s helpful to get exposure to these dermatological presentations, and it’s even more helpful to know that you can’t apply steroid cream to everything hoping that it solves the problem.

So what happened to little Jimmy?
He received IV fluids and a dose of Acyclovir. Leading diagnosis: Eczema herpeticum

What about his Zinc level? What about the wound culture?
…..Stay tuned!