Visual Diagnosis: Teenager with Fever, Petechiae, Confusion, and Weakness

Presentation

A 13-year-old previously healthy girl presents with fever (101.5°F [38.6°C]) for 3 days. It was preceded by generalized headache. The patient reports no history of vomiting, difficulty breathing, coughing, chest pain, blurry vision, speech disturbance, or trauma. The patient also has diffuse muscle pain, although no swelling of limbs or limitation of activity is reported. There is no history of any recent travel, sick contacts, or exposure to animals or insects. She does not report any intravenous drug abuse. Her dental braces were adjusted 2 weeks before admission. Our patient has no previous medical or surgical history. There is no family history of any congenital heart defects, arrhythmia, or frequent infections. She lives with her parents and has a 31-year-old brother, who is healthy.

In the emergency department she has a temperature of 102°F (38.9°C), with associated tachycardia but otherwise normal vital signs. Her physical examination shows an ill-appearing young febrile girl who is alert and oriented to time, place, and person but has trouble recalling events that happened in the past 5 to 7 days. Strikingly, there are multiple nonblanching petechial hemorrhages in the tips of her fingers and toes (Figs 1–3). In addition, tender nodes are appreciated in both palms and soles. The patient also has some weakness of all 4 limbs, but no other notable findings on clinical examination are appreciated. Importantly, auscultation of the heart …