A 10-year-old boy is brought to an urgent care center by his parents due to a rash. The patient awoke yesterday with a rash on his trunk, but his mother says that "it now seems particularly red in his underarms and private area." Over the last 2 days, he has also had headache, fever, and sore throat. He has no allergies, and his immunizations are up to date. Temperature is 38.3 C (101 F), blood pressure is 112/70 mm Hg, pulse is 108/min, and respirations are 20/min. The patient is tired-appearing but playful and in no acute distress. Examination reveals a fine, erythematous, papular rash with a rough texture on the anterior trunk. The rash appears more concentrated in the axillae and groin and blanches with pressure. Tender, shotty, anterior cervical lymphadenopathy is present, and the posterior oropharynx is erythematous with tonsillar exudates and soft palatal petechiae. The father adds, "Two kids in his class had the same symptoms and now have peeling of their hands and feet." What is the most likely diagnosis?

Question

A 10-year-old boy is brought to an urgent care center by his parents due to a rash.  The patient awoke yesterday with a rash on his trunk, but his mother says that "it now seems particularly red in his underarms and private area."  Over the last 2 days, he has also had headache, fever, and sore throat.  He has no allergies, and his immunizations are up to date.  Temperature is 38.3 C (101 F), blood pressure is 112/70 mm Hg, pulse is 108/min, and respirations are 20/min.  The patient is tired-appearing but playful and in no acute distress.  Examination reveals a fine, erythematous, papular rash with a rough texture on the anterior trunk.  The rash appears more concentrated in the axillae and groin and blanches with pressure.  Tender, shotty, anterior cervical lymphadenopathy is present, and the posterior oropharynx is erythematous with tonsillar exudates and soft palatal petechiae.  The father adds, "Two kids in his class had the same symptoms and now have peeling of their hands and feet."  What is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d6d0_fc71_bc81_5731e09cbd4e_MD0003_00 Scarlet fever is an illness caused by group A Streptococcus that develops most commonly in children who have streptococcal pharyngitis. Certain strains of Streptococcus pyogenes produce erythrogenic exotoxins, which are responsible for the characteristic rash of scarlet fever. Fever, sore throat, and headache typically precede the rash, which usually spreads across the trunk, groin, and axillae. The exanthem has a characteristic, finely papular, "sandpaper" texture and is most pronounced in the skin folds. As the illness resolves, desquamation of the rash results in peeling of the hands and feet. "sandpaper" texture An erythematous pharynx with tonsillar exudates, palatal petechiae, and a strawberry tongue are classic findings on examination. The area around the mouth may appear pale in comparison with the red cheeks, giving the appearance of circumoral pallor. Tender, shotty, anterior cervical lymphadenopathy, as seen in this patient, is another nonspecific finding. strawberry tongue circumoral pallor Scarlet fever is managed the same as streptococcal pharyngitis. Diagnosis is confirmed by rapid streptococcal antigen test or throat culture, and treatment is with penicillin. No additional therapy is required for the rash. (Choice A) Erythema infectiosum is caused by parvovirus B19 and causes a classic "slapped cheek", not sandpaper, rash. "slapped cheek" (Choice B) Hand, foot, and mouth disease is a common Coxsackievirus infection that presents in young children with lesions on the hands/feet and oral ulcerations, findings not present in this patient. lesions on the hands/feet (Choice C) Diagnosis of Kawasaki disease (KD) requires 5 days of fever and ≥4 clinical criteria: >1.5 cm cervical node, polymorphous rash, edema of the hands/feet, conjunctivitis, and mucosal changes (eg, strawberry tongue, dry/cracked lips). KD is unlikely in this patient with only 2 days of fever and 2 of the listed criteria. (Choice D) Mononucleosis can present with exudative pharyngitis and a rash; however, posterior cervical lymphadenopathy is typical. (Choice E) Roseola presents with high fever followed by a morbilliform rash that typically erupts once the patient has defervesced. In contrast, this patient with a rash still has fever, making roseola unlikely. morbilliform rash (Choice G) Staphylococcal scalded skin is caused by exfoliative strains of Staphylococcus aureus and presents with superficial flaccid bullae followed by extensive exfoliation of the skin. It is most common in infancy and rarely occurs beyond age 5. Educational objective: Scarlet fever is caused by group A Streptococcus (S pyogenes) and presents with fever, pharyngitis, circumoral pallor, strawberry tongue, and rash. The classic "sandpaper" rash is prominent along skin folds (eg, axillae, groin) and often results in desquamation. References: Pharyngitis and scarlet fever. (http://www.ncbi.nlm.nih.gov/pubmed/26866221)

A 10-Year-Old Boy Is Brought to an Urgent Care Center