Febrile illness in a toddler: The diagnostic clue lays skin deep
A five-year-old boy arrived in Canada fron China. The following day he developed a left cervical swell ing, and was started on oral penicillin at a walk-ln clinic. Subsequently, he developed fever and neck pain. Within 48 h, the left side of his neck was swollen, erythematous and extremely painful. There was no history of cough, weight loss or night sweats. His past history was unremarkable, and all his immunizations were up-to-date. He had received the bacillus Calmette-Guerin (BCG) vaccine in the newborn period as part of the routine vaccination schedule in China. He was the only child of a Chinese couple who had just immigrated to Canada.
On examination, the boy was febrile (38.5°C) and appeared unhappy. His eyes showed bilateral conjunctival erythema. He had left- sided torticollis. The left submandibular lymph node was tender and measured 3X3 cm. The overlying skin showed intense erythema. There was no other lymphadenopathy. The ear, nose and throat examination was normal. The rest of the systemic examination was also normal; in particular, there was no hepatosplenomegaly.
Figure 1) The site of previous bacillus Calmette-Guerin vaccination, as seen during the child’s current febrile illness
He was admitted to hospital and was started on parenteral antibiotics: clindamycin and cefurxime. Investigations revealed a total leukocyte count of 21.12х 109/L: absolute neutrophils 16.5X109/L, bands 1.6×109/L); and lymphocytes 1.27х 109/L). The platelet count was 381×109/L, hemoglobin 108 g/L and sedimentation rate was 97 mm/h; an urinalysis was normal. Serology for Epstein-Barr virus was negative. A Manloux test placed on admislion was negative when read at 48 h. Ultrasound investigation of the neck mass excluded the possibility of an abscess. During hospitalization, he continued to have a fever of 38.5 to 38.8°C. On the fifth day of admission, he was noted to have a rash on the flexor areas, around the large joints, and on his palms and soles. The site of a prior BCG vaccinat ion was raised and erythematous (Figure 1).
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