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Why is the young girl's face red?

This six-year-old was sent home by teachers worried about her rash. Dr Mike Wyndham describes how he came to the right diagnosis


The patient

The mother of this six-year-old girl had been phoned by the school and asked to collect her child as they were unhappy about a rash on her face. They wondered if she was suffering from an allergy and were concerned in case the condition deteriorated. She was fitted in at the end of my morning surgery.

First instinct

No doubt about the red face – she looked as if she was on fire. However, the idea of allergy was quickly dismissed as she told me her skin was not itchy at all. She didn't feel particularly unwell, although her mum said she had eaten less for breakfast than usual. She had a mild fever at 37.2°C. Her throat looked a little red and felt a little sore. There was little in the way of cervical lymphadenopathy and the tongue looked normal.

Differential diagnosis

• Scarlet fever

• Erythema infectiosum

• Erysipelas

Scarlet fever is caused by infection with ß-haemolytic streptococci. It generally makes the child significantly unwell with fever, prominent sore throat, exudates on the tonsils and significant anterior cervical lymphadenopathy. The tongue may take on a white strawberry appearance. This child seemed to score quite low on these. However, the illness does cause a circumoral pallor with red cheeks. The facial appearance could have fitted.

Erythema infection, or slapped cheek syndrome, is caused by human parvovirus B19.

It may be associated with mild sore throat, headache and fever. The cheeks become red with the nasolabial folds often spared. The relatively normal-looking throat would fit with this illness along with its mild impact and the facial appearance.

Erysipelas is usually caused by group A streptococcus infection. It mainly affects adults and causes a painful, well-demarcated rash. There may be significant constitutional upset. This seemed the least likely cause.

Getting on the right track

My overall impression was that this was slapped cheek syndrome. I did not give any medication and advised paracetamol or ibuprofen when required. I warned mum that a new rash resembling a lace cloth was likely to appear on the patient's trunk and limbs a couple of days after our consultation. I explained that there was no need to consult if this happened. A couple of days later when I was clearing my prescription basket, I came across a message confirming that for once, one of my predictions had come true.

Dr Mike Wyndham is a GP in Edgware, north London


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