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A Young Boy With Painful, Erythematous Nodules on Lower Extremities

A Young Boy With Painful, Erythematous Nodules on Lower Extremities

A 5-year old boy presented with these nonpruritic nonsuppurative painful erythematous nodules on his lower extremities. (Figure 1) The rash had appeared about 1 week after the onset of a dry hacking cough. The child had a low-grade fever and joint pain, as well as effusions in his right knee and elbow. 

The child had a history of ADHD and seasonal allergies, which were being treated with methylphenidate CR (40 mg/d) and loratadine (5mg/5ml/d). His mother said his daily routine had not changed but due to cooler weather, he had not been playing outdoors. She said he had not been exposed to any new detergents, medications, soaps, or foods.
 
His mother thought the erythema and inflammation might be an allergic reaction to insect bites and had given the child diphenhydramine 5 mL, every 8 hours for the past 48 hours. However, the lesions increased in number and progressed to larger painful, indurated nodules that covered his lower extremities, ankles, and places on his arms and hands. (Figure 2) Lymphadenopathy was noted only in the supraclavicular area. 

The child also had coarse basilar breath sounds. A chest x-ray film showed peribronchial changes consistent with bronchitis. A sputum culture was positive for Mycoplasma.
 
Differentials included erythema multiforme, MRSA, erythema nodosum (EN), and allergic reaction from an unknown irritant or bite.

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