An Infant’s Sudden-Onset Rash and Swelling: Can You Identify the Cause?

Authors:
Yih Ying (Eva) Yuan, MD; Jo-Ann Nesiama, MD, MS; and Craig Huang, MD

Citation:
Yuan YYE, Nesiama J-A, Huang C. An infant’s sudden-onset rash and swelling: can you identify the cause? Consultant. 2018;58(6):e184.

A previously healthy 5-month-old boy presented to the emergency department (ED) within a few hours of the sudden onset of a rash on his hands, feet, and face along with painful bilateral swelling of the hands and feet. He also had a 4-day history of fever, congestion, and rhinorrhea. The child had no family history of bleeding disorders, and he lived with his parents, his grandmother, and 2 older brothers.

Gross inspection revealed ecchymosis on the infant’s face (Figure 1) and his bilateral upper and lower extremities (Figure 2). Also present was swelling of the bilateral hands and feet, with tenderness to palpation. He was otherwise well-appearing.

Results of a complete blood cell count (CBC), a basic metabolic panel (BMP), urinalysis, and urine and blood cultures were unremarkable except for an elevated white blood cell (WBC) count of 19,000/µL. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level were normal. Radiographs of the pelvis and the bilateral lower extremities showed mild subcutaneous tissue swelling on the bilateral legs and feet without fractures. The patient was discharged from the ED with a scheduled next-day orthopedics outpatient follow-up.

The patient presented to the orthopedics clinic the next day with worsening discoloration of the legs and to buttocks and was directly admitted to the hospital. In the hospital, the results of additional workup, including coagulation tests, a skeletal survey, and repeated CBC, CRP, ESR, and BMP, were unremarkable except for a WBC count of 20,600/µL.