This case presented some interesting problems when it came to the cause of the rash. Was it a viral illness causing an urticarial rash? This diagnosis is supported by the history that the brother has been unwell, the fact that Scarlet has a fever and the subsequent seizure (assumed to be a febrile convulsion). The other possibility is that she has had an allergic reaction to the pesto sauce. She has previously been fine with green pesto and this can usually be safely assumed to contain pine nuts. Pine nuts do not belong to the same ‘family’ as peanuts (they are not tree nuts) and can be tolerated by some people with peanut allergy. But this case demonstrates the importance of reading labels when feeding someone with a known allergy. Whilst most home-made red pesto will still contain pine nuts, some shop-bought ones (including the one that Rachael served) will have other nuts including cashews, increasing the risk of an allergic reaction.
So going through this section you will have hopefully gained an idea of the range of rashes that may affect children. Many are mild and self-limiting but it is important to recognise those that are not. As with all of the cases we have seen, attention to detail is vitally important; the diagnosis you reach should be based on a thorough history and a good examination , noting in particular the vital signs (heart rate, breathing rate, oxygen levels capillary refill time, blood pressure and conscious level). If any of the observations are outside the normal range, you need to have an idea as to why they are abnormal and then test that hypothesis. If the child with a rash and a fever has a high heart rate, you may assume that the fever is to blame. Well test that. Give paracetamol and, if the heart rate does not settle, think again.
The other important things highlighted in this section are around communication with an anxious patient. Cam has a very calming manner but Rachael is clearly agitated. The question, ‘What is worrying you most’ would have revealed her anxiety about the possibility of a febrile convulsion and these concerns could have been addressed head on, ‘I understand your concerns.
She’s not showing any signs that she will have another fit but rest assured that, if she does, we know exactly what to do.’ Parents are usually experts on their own children and a direct question about what is bothering them may reveal things that did not come out in the initial history. Think of the parent, frantic about a non-blanching rash around the eyes of a very well child who has been vomiting. You may be happy that this child is safe and that the increased pressure in the head and neck blood vessels caused by retching may have caused the vomit. How would you feel if that Mum told you that she had a previous child who died from meningococcal sepsis? Listen to parents and take their concerns seriously.