Index of Suspicion

Case 1 Presentation

A 10-month-old boy is referred to the ED for fever, rash, and decreased oral intake. He has asthma, eczema, and a milk-protein allergy. One week ago, he developed a mild cough and rhinorrhea. Three days later, he developed temperatures to 39.9°C but has been afebrile for the past 24 hours. Two days ago, erythematous eczematous patches appeared on his feet. The rash subsequently became vesiculopustular and spread up his legs and to his arms, chest, abdomen, back, and groin. His oral intake and urine output have decreased over the past 24 hours. He has had no diarrhea or vomiting. He has a dog at home, attends child care, and has no travel history. His only medication is occasional levalbuterol.

On physical examination, the boy is afebrile and has normal vital signs. He has enlarged tonsils (2+) with yellow ulcerations; clusters of crusted lesions on the dorsum of his feet and on all four extremities; and scattered vesiculopustules on the dorsum of his hands, toes, back, and groin. All the lesions have surrounding erythema (Figs. 1 and 2). The rest of the physical examination findings are normal.

Polymerase chain reaction (PCR) testing for herpes simplex virus (HSV) and varicella-zoster virus (VZV) from the base of a freshly unroofed vesicle is ordered as well as bacterial cultures of the pustular fluid and crusted lesions. The infant is admitted and started on intravenous (IV) acyclovir and clindamycin. An additional test reveals his diagnosis.

Case 2 Presentation

A 16-year-old girl is transferred from an outlying hospital to the ED for additional evaluation of severe abdominal pain of sudden onset. The pain is constant and localized in the periumbilical and right lower quadrant regions. She denies any fever, anorexia, vomiting, vaginal discharge, or bleeding. …