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Special Feature
December 1, 2008

Picture of the Month—Quiz Case

Author Affiliations

Author Affiliations:Division of Infectious Diseases (Dr Mukundan), University of Toledo College of Medicine (Mr Chang), Toledo, Ohio.



Arch Pediatr Adolesc Med. 2008;162(12):1189. doi:10.1001/archpedi.162.12.1189

A 5-year-old girl was admitted for acute onset of a tender, diffuse, erythematous rash that was present around the eyes, lips, neck, axilla, trunk, genitalia, and extremities. The rash started 4 days prior to admission and was initially present on only the neck and axilla. The patient had increasing pain when she was touched or held, so she was taken to the emergency department. The physician elicited a positive Nikolsky sign, which led to the patient's admission. There was no associated fever or history of skin lesions during this illness. The medical, surgical, psychiatric, and family histories were noncontributory. There was no history of any sick contacts, immunizations were complete for her age, and she had no known drug allergies. The vital signs on admission were a blood pressure of 96/56 mm Hg, a pulse of 113 beats/min, a respiratory rate of 20 breaths/min, and a temperature of 37.6°C. The physical examination results were significant for left cervical lymphadenopathy and enlarged tonsils bilaterally in addition to the rash. The rash was extremely tender, erythematous, and diffuse, involving the neck, axilla, trunk, genitalia, and extremities with increased erythema along the skin creases around the eyes and lips (Figure 1). The absolute neutrophil count was 13 100/μL. The throat, blood, and urine cultures did not yield any growth.