Atypical acral swelling and viral exanthem with parechovirus meningitis

Abstract

We present a case of a febrile 3-month-old infant with atypical acral swelling and erythema for 2 days' duration. He was born full-term via normal vaginal delivery, with no maternal risk factors for sepsis. His parents sought medical attention in view of increasing lethargy and irritability. On physical examination, there was a blanching maculo-papular rash over the trunk and extremities with acral swelling (Figs 1-3). The infant was febrile (maximum temperature 39.8 C) with tachycardia that was out of proportion to fever spikes. His heart rate was in the range of 180-200 beats/min, which raised concerns for underlying sepsis. Intravenous ampicillin and gentamicin were administered immediately. His white cell count was 5.30 × 10 9 /L (5-15 × 10 9 /L; 48% neutrophils, 41% lymphocytes, 10% monocytes) and C-reactive protein level was unremarkable (6.3 mg/L). Blood, urine and cerebrospinal (CSF) cultures were negative. CSF did not reveal any pleocytosis (CSF WBC 0, CSF protein 0.26 g/L). In view of worsening acral erythema associated with swelling, there were concerns of evolving Kawasaki disease (KD).Blood tests were repeated on the third day of hospitalisation due to concerns of KD as child had persistent irritability and fever Fig. 1 Swelling over dorsum of the foot.Fig. 2 Swelling over dorsum of hand. Key Points1 Acral swelling is an uncommon presentation and should raise concerns for Kawasaki disease or parechovirus infection depending on the clinical context. 2 Parechovirus infection is self-limiting and thus prompt isolation of this virus can prevent unnecessary investigations. 3 Parechovirus infection can present with a range of symptoms from being asymptomatic to sepsis-like illness in an infant.

Human parechovirus meningitis in children: state of the art

“…At onset, patients appeared with sepsis-like symptoms and poor general conditions. Fever was the most frequent presenting sign [ 1 , 41 , 44 – 47 , 49 , 50 , 52 – 58 ]. In fact, fever occurrence ranged between 80% and 100% [ 8 , 10 – 12 , 14 , 17 , 21 , 23 , 25 – 28 , 32 , 33 , 60 – 64 , 69 , 70 ].…”

“…Many clinical cases of HPeV CNS infection included a cutaneous sign, as macular or maculo-papular rash, involving mainly truncus and extremities [ 14 , 23 , 41 , 45 , 47 , 54 – 58 , 62 ]. The occurrence of a rash as a presenting sign ranged from 20 to 60% [ 1 , 8 , 11 , 12 , 17 , 21 , 52 , 53 , 60 , 64 , 68 , 69 ].…”

“…Intravenous antibiotics and antiepileptic medicines were administered. Clinical Presentation Alhazmi A, 2020 [ 46 ] Case Report France (Europe) One-month-old baby girl with high fever, irritability, vomiting, and diarrhoea for 36 h Clinical Presentation Chowdhury SR, 2020 [ 47 ] Case Report Singapore (Asia) 3-month-old infant with fever, tachycardia, acral swelling and maculo-papular rash Clinical Presentation Laboratory Imaging Outcome Berk MC, 2018 [ 48 ] Case Report The Netherlands (Europe) A male premature neonate born at 32 weeks and 6 days gestational age presented with sepsis-like symptoms, elevated serum CRP, mild pleocytosis, low level of proteins and normal values of glucose in CSF. Head ultrasounds was normal, MRI showed bifrontal periventricular abnormalities of the white matter.…”

Parechovirus infection in a 12‐year‐old with syncope and seizure

“…There are cases of IV immunoglobulins used for severe infections but randomised control trials are needed to prove their efficacy. 5,10 In conclusion, this case documents the detection of parechovirus on blood PCR in an adolescent who presented with fever and syncope and it shows the importance of considering, and testing for, parechovirus as a causative agent in unwell children of all ages with pyrexia of unknown origin.…”

“…There is currently no effective antiviral treatment for parechovirus infections, and mainstay of treatment is supportive care. There are cases of IV immunoglobulins used for severe infections but randomised control trials are needed to prove their efficacy 5,10 …”