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Autumnal Rash and Fever: Your Dx?


A 2-year-old boy is seen for 2 days of cough, high fever, vomiting, and a rash. Is the rash location a clue to diagnosis? 

Hand, foot, and mouth disease, coxsackie virus

Figure 1. (Please click to enlarge)

Hand, foot, and mouth disease, coxsackie virus

Figure 2. (Please click to enlarge)

Patient History
It is early fall and a 2-year-old boy is brought to the ED by his mother for 2 days of cough, fever as high as 102.2°F, one episode of vomiting, and a rash noted primarily on his left buttock and in and around his mouth. He has no significant medical history, has not been vaccinated recently and is up to date on age- appropriate vaccines.

The mother has not observed any shortness of breath, abdominal pain, or other signs or symptoms.


Vital signs are normal except for a low grade fever of 100.6°F. The physical exam is normal except for the rash. Shown above in Figure 1 is a patch on the left hip/butt area (please click to enlarge). The lungs are clear and the abdomen is benign.

Initial Differential Diagnosis

  • Impetigo
  • Viral syndrome
  • Sepsis
  • Pneumonia

Diagnostic Testing

  • Chest x-ray shows peribronchial cuffing


1. What does the case image show?

2. What should you do next?

Please click here for answers and discussion.



1. What does the case image show?  The rash of hand, foot, and mouth disease. This tends to occur in clusters in pediatric patients in late summer and early fall.

2. What should you do next?  Send home with supportive care

For a brief consult/tutorial: see highlighted area of sample page in Figure 2, at right. (Please click on image to enlarge)


Hand, foot, and mouth disease is a viral illness typically seen in pediatric patients younger than 10 years of age; it is most frequently caused by one of the coxsackie virus strains, and usually occurs in late summer and early fall in clusters. The clinical presentation is classically lesions on the hands and feet and in the mouth, but the rash not infrequently occurs elsewhere, especially the diaper area. Lesions are small papules or vesicles that may eventually ulcerate. Additional symptoms may include fever, anorexia, abdominal pain, vomiting, and cough. Complications are typically neurologic, but are very rare.

The diagnosis is clinical and testing is only indicated to rule out other conditions or complications. Treatment is supportive and symptoms typically last a week or two.

Refer to Figure 2 above for more details.

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