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.
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).
What is the diagnosis?
Henoch-Schonlein purpura (HSP)
Acute haemorrhagic oedema of infancy (AHOI)
What further investigation is required?
Check viral serology including Epstein-Barr virus and hepatitis B virus
Complement levels and autoimmune screen
Lumbar puncture and audiology
No further investigation
How should this child be managed?
Complete 7 days of ceftriaxone treatment
Regular follow-up with urinalysis and blood pressure monitoring
Stop antibiotics if cultures were negative at 48 hours and discharge
Answers are on page▪▪
- General Paediatrics
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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.