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JAMA Pediatrics Clinical Challenge
October 2015

A 6-Year-Old Boy With Fever, Emesis, Rash, and an Acute Abdomen

Author Affiliations
  • 1University of Florida College of Medicine–Jacksonville, Jacksonville
JAMA Pediatr. 2015;169(10):971-972. doi:10.1001/jamapediatrics.2015.1157

A previously healthy 6-year-old boy presented with 6 days of fever (maximum temperature of 40°C), intermittent nonbilious emesis, and 4 days of crampy, diffuse abdominal pain. Physical examination findings were significant for ill appearance, bilateral nonexudative conjunctivitis, shotty bilateral anterior cervical lymphadenopathy, diffuse abdominal tenderness (greatest in the right upper quadrant), and associated rebound and guarding. There was also a blanching, erythematous, macular rash on his cheeks (Figure, A) and an intermittent, erythematous, reticular rash on his chest, abdomen, arms, and legs (Figure, B) that spared his palms and soles and flared with fever. The remainder of his examination findings were unremarkable. Laboratory studies were significant for an elevated aspartate transaminase level of 264 U/L (reference range, 12-47 U/L; to convert to microkatals per liter, multiply by 0.0167) and an alanine transaminase level of 251 U/L (reference range, 17-63 U/L; to convert to microkatals per liter, multiply by 0.0167). A complete blood cell count revealed leukopenia with a white blood cell count of 28 300/µL (to convert to ×109/L, multiply by 0.001) (neutrophils, 64%; lymphocytes, 18%; monocytes, 4%; eosinophils, 2%; basophils, 1%; and bands, 11%), a low-normal hemoglobin level of 11.4 g/dL (to convert to grams per liter, multiply by 10), and thrombocytopenia with a platelet count of 610 × 103/µL (to convert to ×109/L, multiply by 1). Computed tomography of the abdomen revealed a dilated appendix (7 mm) with mucosal hyperemia and an internal appendicolith; acute appendicitis could not be excluded radiographically, so the patient was admitted for further workup because of a concern for acute abdomen. The patient lives in the southeastern United States and had no reported history of unusual exposures or insect or tick bites.

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