By Dr. Jemy Joseph MD CCFP
Dangerous Rashes in a Pediatric Population
Real Clinical Scenario
History of Presenting Illness
A 10-year-old boy developed a rash that is blueish-purple two days ago. It began on his torso, but now has spread to both arms and legs. On his face, it presents only on his tongue. No recent bleeding or trauma.
Past medical history: unremarkable; normal growth and development to date
Medications: none
Allergies: none
Immunizations: none
Recent travel or antibiotics: none
Social History: Grade school; lives at home with both parents and two siblings - all healthy
Family History: no major illnesses in first degree relatives
On Exam
Patient in no apparent distress. Vital signs normal: T 36.9; RR 12; HR 70; BP 104/63; O2 sat 99% room air
Head and neck exam was unremarkable except for rash on tongue
Heart sounds were normal and regular; no murmurs
Respiratory exam revealed no distress; patient did not have any audible or auscultated wheeze
There was no use of accessory muscles
Abdominal exam was benign; no masses or tenderness
Neurologically: normal tone and movement of all limbs
Rheumatological: no joint swelling or redness
Dermatological exam revealed blueish-purple, non-blanchable macular lesions, each <0.2 cm, circular, and all over his body but sparing his face
Impression: Petechiae NYD
Investigations: extensive bloodwork revealed a platelet count of 5 Diagnosis: Immune Thrombocytopenia (ITP)
Treatment: Short-course steroids and monitoring of platelet count until it improves. No blood-thinners or NSAIDs. Avoid intense physical activity or contact sports due to increased risk of bleeding.
Discussion
Pediatric rashes are extremely common and many are benign. In this brief post we won’t go into common rashes. However, as a primary care provider, it is important to recognize the ‘bad’ rashes / rashes that require further work-up / rashes that can resolve with treating underlying illness. Here are some signs to watch out for:
Non-blanching rashes
Petechiae / Purpura (blueish purple and non-blanchable)
Skin layers peeling away (e.g. Stevens-Johnson Syndrome / Toxic epidermal necrolysis)
Vesicular rash (e.g. herpes, chicken pox)
Clear or pus discharge from rashes (e.g. cellulitis)
Fever and rash (e.g. Kawasaki’s)
Rash in a non-immunized child (e.g. Measles, rubella)
Significant pruritus (e.g. lice, scabies)
Target shaped rashes (e.g. tick bites, Lyme disease)
Rash that is not improving within a few days