Last week (20 September, p 668) we described the case of a 2 year old girl with a maculopapular rash, fever, and dehydration. Her general practitioner thought she had a self limiting viral illness but encouraged her father to return with Elisabeth if her symptoms didn't resolve. To look at discussion of the case so far go to bmj.com
Elisabeth returned to nursery. Over the next two weeks she spiked intermittent fevers of up to 39°C (fig 1). Her appetite continued to be poor and she was sleeping more. Although bright and alert at times, she was not her usual self and sometimes became clingy and irritable. Seventeen days after her initial fever, the skin over Elisabeth's fingers and toes peeled (fig 2). Her mother, concerned at this point, contacted an anaesthetist colleague. Elisabeth was seen at her local hospital by a paediatrician.
The paediatrician noted Elisabeth was irritable. Her temperature was 37°C. She had no rash. Her tongue and eyes were normal and her throat mildly inflamed. She had bilateral palpable cervical lymph nodes. No evidence of peripheral desquamation was noted. There were no abnormalities detected on examination of her chest, cardiovascular system, or abdomen.
Chest radiography and a 12 lead electrocardiogram showed no abnormality. Her blood tests, including analyses for haemoglobin, lymphocytes, and platelets, gave normal results. Her white blood cell count was raised at 20.7×108/l with a neutrophil count of 13×108/l. Her C reactive protein concentration was also raised (13 mg/ml; reference < 5 mg/l).
Questions
This doesn't look like a simple viral illness now. What do you think the diagnosis could be?
How would you manage Elisabeth's illness now?
What would you say to Elisabeth's parents?
Please respond through bmj.com
This is part 2 of a 3 part case report where we invite readers to take part in considering the diagnosis and management of a case using the rapid response feature on bmj.com. In three weeks' time we will report the outcome and summarise the responses
Competing interests: None declared.
We welcome contributions of interactive case reports. Cases should raise interesting clinical, investigative, diagnostic, and management issues but not be so rare that they appeal to only a minority of readers.
Full details of criteria are available at: bmj.com/cgi/content/full/3267/7389/564/DC1