Index of SuspicionCase 1: Perinasal and Perioral Rash in a 2-year-old GirlCase 2: Intractable Myoclonic Seizures in a 2-year-old BoyCase 3: A 2-month-old Girl Who Has Failure to Thrive, Neutropenia, and Anemia

Case 1 Presentation

A 2-year-old white girl presents with a 2-month history of a rash around her mouth and nose. On examination, she has perioral and perinasal pink papules and papulopustules, which coalesce to form thin plaques, as well as occasional periorbital papules and a small area of crusting in the perinasal region (Fig 1). The rash is nonpruritic but accompanied by a burning sensation. Notably, the patient’s vermilion border is spared.

Her past medical history is significant for a congenital cystic adenomatoid malformation (surgically resected at 6 weeks of age), atopic dermatitis, seasonal rhinitis, and asthma, requiring fluticasone propionate (44 mcg/puff twice daily) via a metered dose inhaler with spacer and face mask for the past 6 months (Fig 2). The dermatitis has been treated with over-the-counter cream and ointment without relief, but no topical products containing hydrocortisone have been used. The patient is seen by a dermatologist for the cause of the persistent facial rash, and her history and findings on physical examination lead to a presumptive diagnosis.

Case 2 Presentation

A 2-year-old boy presents with a history of seizures since the age of 9 months. The first episode started as a febrile seizure and led to status epilepticus. He was diagnosed as having generalized epilepsy of unknown origin after evaluation by a neurologist and EEG. The seizure activity initially was generalized and tonic-clonic in nature. He would drop and exhibit jerking movements of the arms and legs, followed by generalized tonic posturing, accompanied also by rolling back of the eyes, drooling, and oral cyanosis. Recently, however, his seizures have consisted of myoclonic jerks, mainly of the …