A 2 Year old with fever

by Bob Stuntz


The following case was submitted by Krystle Shafer, MD (pictured above).  Dr. Shafer is an EM-1 at my institution.  She went to University of Maryland (just like me, fear the Turtle!) for medical school.  She has a special interest in pediatrics and critical care, and we will certainly be hearing more from her down the road.

A one and a half year old female presents to the emergency department with a chief complaint of high fever with a home rectal temperature reported as 105 F despite administration of tylenol. Her fever initially started four days ago with tmax of 102.7 F. She has seen her pediatrician twice over the past four days who provided reassurance that this was a viral illness and advised to continue tylenol at home; despite this treatment, every day her fever has gotten higher and higher. On day two of her illness her parents report that they noted the development of an itchy rash that initially started as a couple bumps on her chest and back.   However, as her fever increased her rash became blotchier and more confluent such that it now covers her entire body, sparing the palms and soles. The day prior to her emergency department visit mom reports that the child stopped drinking pedilyte secondary to complaints that it is burning her mouth. Mom also notes that yesterday her eyes looked red and that the tip of her tongue was also bright red.  Today she has noted a white film covers her tongue. Review of systems is positive for a nonproductive cough and vomiting once during the course of her illness.

Physical exam reveals rectal temp 104.3F, mild tachycardia for her age, and a mildly increased respiratory rate.  She is in mild distress, but has no significant increased work of breathing.  HEENT reveals bilateral conjunctival injection, posterior cervical lymphadenopathy, and white patches on tongue.  Her lungs are CTAB.  CV exam shows the heart to have a regular rate/rhythm with no murmur.  She has a diffuse maculo-papular rash that spares the palms and soles.

1. Based on the information provided, what is the suspected diagnosis? 

2.  What diagnostic tests, if any, would you perform?

3.  What is the pathology of this condition? What is the treatment and disposition if your suspected diagnosis is correct?

4. Mom is currently in her first trimester of pregnancy with her second child.  Is this diagnosis potentially harmful to the fetus?