What is that rash?

Case history A healthy 15-month-old girl presented to the emergency department with a 24-hour history of fever and rash. The initial blanching rash developed into non-blanching areas with associated leg swelling. She had received no recent medications, had no known drug allergies and no unwell contacts. On examination, she was feverish at 38.6°C, capillary refill time was <2 s with warm peripheries, heart rate 169 bpm and blood pressure 94/59 mm Hg. A palpable purpuric rash was evident on all four limbs and face (figure 1) although the trunk was spared. Her legs were tense and oedematous to the knee. Figure 1 Rash at presentation. Initial investigations: Haemoglobin level: 131 g/L, white cell count: 16.6×109/L, neutrophils: 11.1×109/L and platelets: 407×109/L Coagulation screen: normal C reactive protein level: 20 mg/L Lactate level: 1.7 mmol/L Intravenous ceftriaxone was commenced following blood culture and meningococcal PCR. The following day, while remaining systemically well, she developed a vesicular rash on her trunk and back (figure 2). Figure 2 Vesicular rash. Questions What is the diagnosis? Henoch-Schonlein purpura (HSP) Meningococcal septicaemia Acute haemorrhagic oedema of infancy (AHOI) Vasculitic urticaria Gianotti-Crosti syndrome What further investigation is required? Check viral serology including Epstein-Barr virus and hepatitis B virus Complement levels and autoimmune screen Skin biopsy Lumbar puncture and audiology No further investigation How should this child be managed? Complete 7 days of ceftriaxone treatment Oral aciclovir Oral steroids Regular follow-up with urinalysis and blood pressure monitoring Stop antibiotics if cultures were negative at 48 hours and discharge Answers are on page▪▪