Pediatrics 403375.A 21-month-old girl, previously well, presents with 7 days of fever
and rash. She has been seen previously during this episode by her primary
physician and diagnosed with a “viral illness.” On further questioning, the
mother indicates that the patient has had red eyes, but no discharge. She
has had no vomiting, diarrhea, cough, congestion, or complaints of pain.
She has, however, seemed very irritable and fussy throughout the last few
days and cannot seem to get comfortable. On examination, the patient is
highly irritable and intermittently consolable. Vital signs reveal Tempera-
ture 101°F rectally, HR 170 beats per minute, RR 22 breaths per minute, BP
100/60 mm Hg. Her conjunctivae are mildly injected with no purulent dis-
charge. The oropharynx is clear though she has dry, cracked lips. There are
two anterior cervical nodes measuring 2.5 cm each. The heart is tachy-
cardic without a murmur. The lungs are clear and abdomen is soft and
nontender with no hepatosplenomegaly. The skin reveals a diffuse, blanch-
ing, erythematous, macular rash. The extremities have no swelling or ten-
derness. Laboratory evaluation reveals WBC 13,500/μL, Hgb 9.5 mg/dL,
platelets 870/μL, CRP 89, ESR 85, electrolytes are normal, liver function
tests reveal aspartate aminotransferase (AST) 110 U/L, alanine aminotrans-
ferase ALT 88 U/L. Which of the following is the most appropriate next
step in the management of this patient?
a. Consult cardiology for statim (STAT) echocardiogram
b. Additional laboratory tests including Epstein-Barr viral titers, strep test, anti-
nuclear antibody, bone marrow biopsy
c. Reassurance to the parents that the initial diagnosis was probably accurate
d. Administer IV antibiotics and perform lumbar puncture
e. Admit for administration of intravenous immunoglobulin (IVIG) and aspirin