A 2 year old child with rash and fever

Elisabeth first became unwell during the evening of her 2nd birthday. Her parents noticed that she was “grizzly and off her food.” Later that night she woke with a temperature of 38.9°C. During the next two days her fever, lethargy, and irritability persisted despite regular paracetamol. Her fluid intake was poor. On the second evening her mother noticed that Elisabeth was very thirsty but cried whenever she put a cup to her mouth. Her tongue was brick red, furrowed, dry, and seemed painful. Her eyes were inflamed and had a watery discharge. She had a faint rash on her left thigh, back, and face. Her perineum had started to peel. By the following afternoon (day 3) Elisabeth had had a dry nappy for 24 hours, and her mother contacted her local out of hours service. She received advice to encourage fluids and to continue to administer an antipyretic. The following evening Elisabeth's temperature had reverted to normal and she had started drinking.

On Monday morning (day 5) Elisabeth was due to go back to nursery. She still had no appetite but her temperature was normal. Her rash was fading and her tongue symptoms had resolved. Nursery policy required her to see a doctor before returning. Her general practitioner noted an alert little girl with a maculopapular rash on her trunk and perineal desquamation (figure). Her ears, throat, and chest appeared normal.

Figure 1.

Maculopapular rash in baby with symptoms similar to this case

Credit: JKI

Questions

1. What do you think is wrong with Elisabeth?

2. What other tests would you do now?

3. What should Elisabeth's general practitioner say to her parents?

Please respond through bmj.com/cgi/eletter-submit/327/7416/668

Elisabeth has received all her childhood vaccinations to date. She is an only child. Her mother, an anaesthetist, is in the second trimester of pregnancy. Her father, a teacher, has adult onset asthma, nasal polyps, and a severe aspirin allergy. At 8 months of age, Elisabeth developed temporary milk intolerance and oral candidiasis. She had two episodes of periorbital cellulitis and an irritable hip at 1 year.