Visual Diagnosis: An Uncommon Presentation of a Common Rash

Presentation

A 3-year-old boy is admitted to the hospital with rapid onset of a rash and swelling of the hands and feet. The rash began a day earlier, first noticed on the abdomen and legs, and spreading cephalad to the head, neck, and arms. His parents noted intermitted rhinorrhea for 1 week prior, without fever, cough, stridor, arthralgia, or myalgia. There was no evidence of dysphagia or odynophagia as he was eating and drinking normally. Immunizations were up to date, although he had not recently been immunized or taken any medications. The family lives on a farm where they spend significant time outdoors, noting daily contact with cows, pigs, and chickens and drinking unpasteurized milk. The parents did see a mosquito bite on his left temple the week before, which resolved without concern. The current rash was initially pruritic, responding to a dose of diphenhydramine. The medical history is notable for recurrent otitis media with placement of tympanostomy tubes and a single febrile seizure. His mother and maternal grandmother …