Clinical Review Interactive case report

A 2 year old child with rash and fever

BMJ 2003; 327 doi: (Published 25 September 2003) Cite this as: BMJ 2003;327:720
  1. Rita Sharma, clinical lecturer1,
  2. Andrew Boon, consultant paediatrician2,
  3. Anthony Harnden, university lecturer (anthony.harnden{at}
  1. 1Department of Primary Health Care, Institute of Health Sciences, Oxford OX3 7LF
  2. 2Royal Berkshire Hospital, Reading RG1 5AN
  1. Correspondence to: A Harnden

    Last week (20 September, p 668) we described the case of a 2 year old girl with a maculopapular rash, fever, and dehydration. Her general practitioner thought she had a self limiting viral illness but encouraged her father to return with Elisabeth if her symptoms didn't resolve. To look at discussion of the case so far go to

    Elisabeth returned to nursery. Over the next two weeks she spiked intermittent fevers of up to 39°C (fig 1). Her appetite continued to be poor and she was sleeping more. Although bright and alert at times, she was not her usual self and sometimes became clingy and irritable. Seventeen days after her initial fever, the skin over Elisabeth's fingers and toes peeled (fig 2). Her mother, concerned at this point, contacted an anaesthetist colleague. Elisabeth was seen at her local hospital by a paediatrician.

    Fig 1
    Fig 1

    Elisabeth's temperature chart showing intermittent swinging fever

    Fig 2
    Fig 2

    Peripheral desquamation

    Credit: JKI

    The paediatrician noted Elisabeth was irritable. Her temperature was 37°C. She had no rash. Her tongue and eyes were normal and her throat mildly inflamed. She had bilateral palpable cervical lymph nodes. No evidence of peripheral desquamation was noted. There were no abnormalities detected on examination of her chest, cardiovascular system, or abdomen.

    Chest radiography and a 12 lead electrocardiogram showed no abnormality. Her blood tests, including analyses for haemoglobin, lymphocytes, and platelets, gave normal results. Her white blood cell count was raised at 20.7x108/l with a neutrophil count of 13x108/l. Her C reactive protein concentration was also raised (13 mg/ml; reference < 5 mg/l).


    1. This doesn't look like a simple viral illness now. What do you think the diagnosis could be?

    2. How would you manage Elisabeth's illness now?

    3. What would you say to Elisabeth's parents?

    Please respond through

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    • Competing Interests None declared.