Picture of the Month

摘要

AN 11-YEAR-OLD BOY DEVELOPED A GENERAL-ized erythematous macular rash 5 weeks prior to hospitalization. The rash resolved in 3 weeks but he then developed fevers and a sore on his inner left arm (Figure 1). The lesion was painful and red. One week prior to hospital admission, a complete blood cell count revealed a low white blood cell count of 3.6 X 10~3/uL with a normal hemoglobin concentration and platelet count. A sore throat was present and he complained of oral ulcers. On hospital admission, he was ill appearing and febrile (40癈), with marked oral ulceration. In addition to an eschar measuring 1.5 cm on his left upper arm with underlying induration (Figure 1). he had a tender lymph node in the nearby axilla. His laboratory test results showed a white blood cell count of 1.6 X 10~3/uL (12% band forms, 67% segmented neutrophils, 20% lymphocytes), a hemoglobin concentration of 9.4 g/dL, and a platelet count of 71X 10~3/uL. His fibrin split products were elevated and the fibrinogen level was falling.His serum ferritin level was 18 070 ng/mL (40 603 pmol/L). His C-reactive protein level was elevated at greater than 20 mg/dL, but surprisingly, his erythrocyte sedimentation rate was normal at 5 rnrn/h. His serum and urine electrolyte levels were consistent with syndrome-inappropriate antidiuretic hormone, and his uric acid and lactate dehydrogenase levels were elevated. Epstein-Barr virus testing was consistent with prior infection.