Wednesday, October 22, 2014

3 Year-Old with Fever and Rash

Presented by Sylvia Moscone, M.D.
Block Island, New York

The patient is a 3-year-old girl who was seen for evaluation of a solitary lesion on the midback that has been present for about four days.  At the onset, she had a high fever, 105-106 F.  She was seen in the ER and referred to her pediatrician.  A diagnosis of Lyme disease was made and the patient was started on amoxicillin.  Blood studies were drawn.  Over the next two days, the fever persisted and then disappeared two days ago.  The child has a good appetite, sleeping well, playing normally.  Her parents feel she is "grumpy." She says the area on her back hurts. 

O/E:  The examination shows a 3 cm in diameter somewhat circular, erythematous scaly area.  A portion of this is flesh-colored.  There are no other similar lesions and there is no lymphadenopathy.   A baseline photo, taken by her mother, shows the initial lesion to be larger.

Clinical Photos:
At onset with fever
Four days later
Lab:  Lyme titers are negative.  Titers for Ehrlichiosis and Bartonellosis may have been drawn, but are not available now.

IMPRESSION:   A lesion less than 5 cm in diameter that is not enlarging is unlikely to be Lyme disease.  I do not have a specific diagnosis here. However, the lesion in the initial photo, taken by the child's mother may well have been > 5 cm in diamedter.  I woulld appreciate some guidance from VGRD members.  For the time being, the child is doing very well and she will be observed.  

Comment:  In the initial photo taken by the patient's mother, the lesion looks to be ~ 5 cm or larger.  This would suggest Lyme disease.  High fever is unusual with Lyme disease so the question of co-infection with Ehrlichiosis or Babesiosis needs to be considered.  Amoxicillin is not effective for those disorders, but many cases resolve spontaneously.    For the time being, it might be best to observe this child.  Serologies for the latter two diagnoses could be drawn if they were not looked for initially.