Scarlet fever associated with Rhabdomyolysis in a 2-year-old female.

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History (including chief complaint, history of present illness and relevant past and family medical history): 2 year old female child brought by the mother with a c/o of refusal to walk and bear weight for 1 day. She had fever T-max of 103 F and URI symptoms for 3 days, associated with decrease oral intake and 2 episodes of non-bloody, non-bilious vomiting. One week prior admission, there is history of fall while paying with no subsequent join swelling or pain. No dark color of the urine, diarrhea, skin rash, lethargy, sick contacts, recent travel, pets or exposure to cats reported. No history of ingestion of chronic medication use, except for ibuprofen and Tylenol for the fever. No significant past medical history. Family history noncontributory.

 Physical examination findings (including vital signs): Initial vitals no fever or tachycardia. She appeared to be in pain and was non-ambulatory. On physical examination normal HEENT; no evidence of otitis media or pharyngitis. Extremities showed limitation of range of motion in lower limbs due to pain, more pronounced on dorsiflexion of both feet. Her preferred position was extension of legs with plantarflexed feet. Reflexes and sensations were within normal limits, with no vascular compromise noted. Dorsalis pedis pulses (+2) were palpated bilaterally. There was no skin rash noted on admission. 

Laboratory or Diagnostic imaging or Procedures: 

On admission Normal CBC, BMP, CRP. EKG showed normal sinus rhythm. Blood culture and urine culture were negative. Because of the history of fever, rash and refusal to ambulate, CPK was elevated 7036U/L (Normal value 20 to 200U/L) Initial LFTs with elevated Aspartate Transaminase of 369U/L (Normal: 13-35U/L and Alanine Transaminase of 135 U/L (Normal: 5-45U/L) Urinalysis negative for microscopy RBCs, WBCs or myoglobin. Heterophile antibodies and EBV serology were negative. ASLO titers were <50 on admission (Normal range <100 Todd U/ml in <5 years). RVP was negative.

Final Diagnosis: On day 2 of admission, she continued spiking fevers and developed a diffuse sandpaper-like rash covering the trunk and extremities, prompting testing for GAS. Scarlet fever and Rhabdomyolysis was diagnosed, and she was started on IV Ceftriaxone. Her symptoms gradually improved, she was eventually able to dorsiflex her feet without pain, with a trend down of CPK and LFTs. Repeated ASO titers 1 month after trend up confirm the diagnosis. We present a rare case of Scarlet fever associated with Rhabdomyolysis. There are reports of rhabdomyolysis associated with GAS infection in adults, but it is rarely reported in children. The clinical symptoms of extremity weakness with fever should prompt clinicians to evaluate for rhabdomyolysis and have a GAS as an etiology of it.

BronxCare Health System
Bronxcare Health System
Dept. of Pediatrics, BronxCare Health System

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