Erythema multiforme presentation in a 4-yr-old
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A previously healthy, 4-year-old female with unusual skin lesions and mouth sores. The rash began on her face and spread to the body and extremities in no particular pattern, with simultaneous onset of sores in her mouth. Two weeks earlier, she had a hoarse voice with some fever and was seen by her provider, who diagnosed her with an upper respiratory tract infection. She seemed to be better after about 4 days and remained well until just a few days prior to this visit.

She had about 50 discrete, round, erythematous lesions, surrounded by normal-appearing skin. The lesions were of various size, with some having dark-to-black-appearing centers. On close examination, some lesions appeared to have small vesicles in the center. Her mouth and lips were found to have several ulcerative lesions. Her other mucous membranes, including her eyes, were clear. She improved clinically with IV fluids, with no progression of mouth sores or the skin rash during this hospitalization of only a few days.

A herpes simplex virus (HSV) PCR of one of the skin lesions was negative. 8 months later, the patient presented with a similar episode of stomatitis only, without rash. The answer confirmed by dermatology was erythema multiforme, or EM. This condition is characterized by fixed, target-like lesions, often with necrotic centers. Many experts feel that the most common trigger for this condition is infection with HSV. With mouth and lip ulcerative lesions, HSV could very well have been the cause, although EM lesions can appear in this area as well.

However, the HSV test was done on a skin lesion, which one would not expect to be positive, as these are reactions to the infection, not a local HSV infection.

Lessons learnt:-
- In cases triggered by HSV infections, recurrence is occasionally seen, which hints that the patient was having an additional episode of stomatitis 8 months later.

- It should be noted that if there is any question of ocular involvement, an ophthalmologist should be involved early on. Such was not the case with this patient.

- Treatment is supportive and, if due to HSV, acyclovir should be used.

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