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Visual Diagnosis: Rash and Fatigue in a 6-year-old Girl

Jonathan C. Schroeder, Travis Frantz, Andrew W. Osten and Sunghun Cho
Pediatrics in Review April 2021, 42 (4) e13-e16; DOI: https://doi.org/10.1542/pir.2018-0218
Jonathan C. Schroeder
*Department of Pediatrics and
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Travis Frantz
†Wake Forest School of Medicine, Winston-Salem, NC
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Andrew W. Osten
*Department of Pediatrics and
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Sunghun Cho
‡Department of Dermatology, Tripler Army Medical Center, Honolulu, HI
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  1. Jonathan C. Schroeder, MD*
  2. Travis Frantz, MD†
  3. Andrew W. Osten, MD*
  4. Sunghun Cho, MD‡
  1. *Department of Pediatrics and
  2. ‡Department of Dermatology, Tripler Army Medical Center, Honolulu, HI
  3. †Wake Forest School of Medicine, Winston-Salem, NC
  • AUTHOR DISCLOSURE

    Drs Schroeder, Frantz, Osten, and Cho have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Presentation

A 6-year-old girl with a complex cardiac history that includes transposition of the great vessels status-post repair presents to the general pediatric clinic for a routine well-child examination. Her mother, present during the appointment, is concerned that the patient developed an itchy rash on her face last month, which has since spread to her elbows. Her rash had been diagnosed as eczema 2 weeks previously. She has been using 1% hydrocortisone cream on her face twice a day for 2 weeks and emollients several times per day without any relief. Along with her rash, she also feels tired when she plays for too long. She lies down to rest after play sessions and fatigues easily when walking up stairs. She does not have difficulty getting out of bed or rising from a chair. On review of systems, her mother does not report that she has fevers, joint pain, joint swelling, weight loss, headaches, vision changes, urinary issues, heart palpitations, or swollen lymph nodes. Examination of her skin reveals a macular, nonblanching, erythematous, scaly rash on the central face, including the nasolabial folds and the upper lateral sidewall of the nose (Fig 1). She also has erythematous plaques with scaling over both elbows and knees (Fig 2). Muscle strength testing reveals subtle weakness on adduction of her arms.

Figure 1.

Pink-violaceous patches over the upper eyelids. Pink scaly macules and patches over the nasolabial and melolabial folds.

Figure 2.

Violaceous flat-topped papules coalescent on skin overlying the knees and surrounding skin.

Laboratory studies reveal that her antinuclear antibody test is positive at 1:640 (normal ≤1:40). Her aspartate aminotransferase level is elevated at 58 …

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Pediatrics in Review: 42 (4)
Pediatrics in Review
Vol. 42, Issue 4
1 Apr 2021
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Visual Diagnosis: Rash and Fatigue in a 6-year-old Girl
Jonathan C. Schroeder, Travis Frantz, Andrew W. Osten, Sunghun Cho
Pediatrics in Review Apr 2021, 42 (4) e13-e16; DOI: 10.1542/pir.2018-0218

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Visual Diagnosis: Rash and Fatigue in a 6-year-old Girl
Jonathan C. Schroeder, Travis Frantz, Andrew W. Osten, Sunghun Cho
Pediatrics in Review Apr 2021, 42 (4) e13-e16; DOI: 10.1542/pir.2018-0218
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