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Practice scenario: maculopapular rash in young boy

The parents of a six-year-old boy come to see you. They tell you that Jake has been poorly for the past two days. He complained originally of a sore throat but, while that is getting better, Jake now has a temperature and they have also noticed a distinctive rash spreading up his trunk. He is normally fit and healthy with no other medical problems. What do you advise?

Problem representation

A six-year-old boy presents with a two-day history of acute onset constitutional symptoms with associated rash. 

Hypothesis generation 

Morphologically, a maculopapular rash is a mixture of macules (flat skin lesions ≤1cm in diameter) and papules (elevated, solid skin lesions ≤1cm in diameter). 

A maculopapular rash can be defined as a smooth skin rash or redness covered by elevated bumps. It is also referred to as morbilliform eruption or exanthematous eruption (exanthema – skin rash accompanying a disease or fever).

It can be characterised as acute (less than 4 weeks’ duration), sub-acute (4-8 weeks) or chronic (>8 weeks). Rashes represent a diagnostic challenge but are commonly caused by infections in children and allergy in adults. 

As you are dealing with a seven-year-old child, your first thoughts on the conditions that are a common cause of his symptoms would be:

Likely diagnosis 

  • Erythema infectiosum (Fifth disease)
  • Hand, foot and mouth (HFM)
  • Roseola infantum (Sixth disease, exanthem subitum) – all viral.

Unlikely diagnosis 

  • Allergies
  • Drug eruptions
  • Erythema multiforme
  • Infectious mononucleosis
  • Infectious causes from endemic regions
  • Rubella (German measles)
  • Rubeola (measles) or scarlet fever.

Critical diagnosis  

  • Cutaneous lupus erythematosus
  • Juvenile idiopathic arthritis
  • Kawasaki disease
  • Rubella or rubeola complications.
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