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What is that rash?
  1. Lynne Speirs,
  2. Steven McVea,
  3. Rebecca Little,
  4. Thomas Bourke
  1. Royal Belfast Hospital for Sick Children, Belfast, UK
  1. Correspondence to Dr Lynne Speirs, Royal Belfast Hospital for Sick Children, 180–184 Falls Road, Belfast BT12 6BE, UK;


Case history A healthy 15-month-old girl presented to the emergency department with a 24-hour history of fever and rash. The initial blanching rash developed into non-blanching areas with associated leg swelling. She had received no recent medications, had no known drug allergies and no unwell contacts.

On examination, she was feverish at 38.6°C, capillary refill time was <2 s with warm peripheries, heart rate 169 bpm and blood pressure 94/59 mm Hg. A palpable purpuric rash was evident on all four limbs and face (figure 1) although the trunk was spared. Her legs were tense and oedematous to the knee.

Figure 1

Rash at presentation.

Initial investigations:

  • Haemoglobin level: 131 g/L, white cell count: 16.6×109/L, neutrophils: 11.1×109/L and platelets: 407×109/L

  • Coagulation screen: normal

  • C reactive protein level: 20 mg/L

  • Lactate level: 1.7 mmol/L

Intravenous ceftriaxone was commenced following blood culture and meningococcal PCR. The following day, while remaining systemically well, she developed a vesicular rash on her trunk and back (figure 2).


  1. What is the diagnosis?

    1. Henoch-Schonlein purpura (HSP)

    2. Meningococcal septicaemia

    3. Acute haemorrhagic oedema of infancy (AHOI)

    4. Vasculitic urticaria

    5. Gianotti-Crosti syndrome

  2. What further investigation is required?

    1. Check viral serology including Epstein-Barr virus and hepatitis B virus

    2. Complement levels and autoimmune screen

    3. Skin biopsy

    4. Lumbar puncture and audiology

    5. No further investigation

  3. How should this child be managed?

    1. Complete 7 days of ceftriaxone treatment

    2. Oral aciclovir

    3. Oral steroids

    4. Regular follow-up with urinalysis and blood pressure monitoring

    5. Stop antibiotics if cultures were negative at 48 hours and discharge

Answers are on page▪▪

  • General Paediatrics
  • Dermatology

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  • Contributors LS, SMcV and RL contributed equally to the authorship. TB was the supervising consultant.

  • Competing interests None.

  • Patient consent Parental/guardian consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.