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.

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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).

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Figure 2

Vesicular rash.

Questions

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

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