Febrile Illness in a Toddler: The Diagnostic Clue Lays Skin Deep

A five-year-old boy ar rived in Can ada fron China.The fol low ing day he de vel oped a left cer vi cal swel ling, and was started on oral peni cil lin at a walk-in clinic.Sub se quently, he de vel oped fe ver and neck pain.Within 48 h, the left side of his neck was swol len, eryth ema tous and ex tremely pain ful.There was no his tory of cough, weight loss or night sweats.His past his tory was un re mark able, and all his im mu ni za tions were up-to-date.He had re ceived the ba cil lus Calmette-Guérin (BCG) vac cine in the new born pe riod as part of the rou tine vac ci na tion sched ule in China.He was the only child of a Chi nese cou ple who had just im mi grated to Can ada.On ex ami na tion, the boy was feb rile (38.5°C) and ap peared unhappy.His eyes showed bi lat eral con junc ti val ery thema.He had leftsided tor ti col lis.The left sub man dibu lar lymph node was tender and meas ured 3×3 cm.The over ly ing skin showed in tense ery thema.There was no other lym pha de no pa thy.The ear, nose and throat exami na tion was nor mal.The rest of the sys temic ex ami na tion was also nor mal; in par ticu lar, there was no he pa tospleno megaly.He was ad mit ted to hos pi tal and was started on par enteral an ti biot ics: clin da my cin and ce furxime.In ves ti ga tions re vealed a to tal leuko cyte count of 21.12×10 9 /L: ab so lute neu tro phils 16.5×10 9 /L, bands 1.6×10 9 /L); and lym pho cytes 1.27×10 9 /L).The plate let count was 381×10 9 /L, he mo glo bin 108 g/L and sedi men ta tion rate was 97 mm/h; an uri naly sis was nor mal.Serology for Epstein-Barr vi rus was nega tive.A Man toux test placed on ad mis sion was nega tive when read at 48 h.Ul tra sound in ves ti ga tion of the neck mass ex cluded the pos si bil ity of an ab scess.Dur ing hos pi tali za tion, he con tin ued to have a fe ver of 38.5 to 38.8°C.On the fifth day of ad mis sion, he was noted to have a rash on the flexor ar eas, around the large joints, and on his palms and soles.The site of a prior BCG vac ci na tion was raised and ery the ma tous (Fig ure 1).What is the di ag no sis?

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