Febrile Illness in a Toddler: The Diagnostic Clue Lays Skin Deep

Afive- year- old boy ar rived in Can ada fron China. The fol low ing day he de vel oped a left cer vi cal swel ling, and was started on oral peni cil lin at a walk- in clinic. Sub se quently, he de vel oped fe ver and neck pain. Within 48 h, the left side of his neck was swol len, eryth ema tous and ex tremely pain ful. There was no his tory of cough, weight loss or night sweats. His past his tory was un re mark able, and all his im mu ni za tions were up- to- date. He had re ceived the ba cil lus Calmette- Guerin (BCG) vac cine in the new born pe riod as part of the rou tine vac ci na tion sched ule in China. He was the only child of a Chi nese cou ple who had just im mi grated to Can ada. On ex ami na tion, the boy was feb rile (38.5°C) and ap peared un happy. His eyes showed bi lat eral con junc ti val ery thema. He had leftsided tor ti col lis. The left sub man dibu lar lymph node was tender and meas ured 3×3 cm. The over ly ing skin showed in tense ery thema. There was no other lym pha de no pa thy. The ear, nose and throat ex ami na tion was nor mal. The rest of the sys temic ex ami na tion was also nor mal; in par ticu lar, there was no he pa tospleno megaly. He was ad mit ted to hos pi tal and was started on par enteral an ti bi ot ics: clin da my cin and ce furxime. In ves ti ga tions re vealed a to tal leu ko cyte count of 21.12×10 9