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Preschooler With Slowly Progressing Rash on One Arm

Preschooler With Slowly Progressing Rash on One Arm

During the past week, a rash on the right thumb and forefinger of a 4-year-old boy has progressed to involve the entire arm.

The boy’s parents first noted the digital lesions during a family vacation at a mountain resort where the child had been swimming and playing outdoors. The resort grounds were well maintained; no wild animals had been seen on the premises. All family members had been healthy during the vacation.

The rash on the boy’s fingers spread to the rest of the hand and then up the forearm. The eruption stopped at the shoulder and did not spread to the torso. The rash was not pruritic, but the affected area was painful. The youngster remained afebrile but complained of pain and constant fatigue. His parents treated him with acetaminophen, which diminished the pain, and topical hydrocortisone, which did not help resolve the rash.

The boy’s parents now seek the pediatrician’s advice 7 days after the initial appearance of the lesions. The boy’s vital signs are stable. He appears somewhat tired but remains active. The only notable findings are small vesicles on the right arm with areas of healing and scabbing (Figures 1 and 2). The arm is tender to palpation, but there is no soft tissue swelling or induration. There is full range of motion, but voluntary arm movements are diminished. The patient says the rash is less painful now than it was earlier in the week.

Except for the removal of a branchial cleft cyst at age 2, the child’s medical history is unremarkable. The patient has not had chickenpox; he received live varicella virus vaccine when he was 12 months old.

Herpes zoster secondary to varicella vaccine is diagnosed and is confirmed by a polymerase chain reaction assay. The patient is treated with oral acyclovir, and his lesions and symptoms resolve fully within 2 weeks.

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