15-Month-Old Male with Acute Onset Palmar Erythema

Case at a Glance

A 15-month-old previously healthy male presented with a 3-day history of bilateral palmar erythema, associated with mild constitutional symptoms including rhinorrhea, loose stools, and irritability.

Patient's Story

The patient's parents brought their 15-month-old son to the clinic with concerns about sudden onset of red palms that appeared 3 days prior. The child weighed 25 pounds and had been previously healthy with no significant medical history. Parents reported the child remained afebrile but exhibited mild irritability, loose stools, rhinorrhea, and slight conjunctival erythema. A diaper rash was also noted. Despite these symptoms, the child maintained good oral intake and appetite.

Initial Assessment

Physical examination revealed bilateral palmar erythema without pustules or vesicular lesions. The patient was afebrile with mild conjunctival injection and rhinorrhea. Diaper area showed erythematous rash. No pedal involvement was observed. The child appeared well-hydrated and alert, though somewhat irritable during examination.

The Diagnostic Journey

The attending nurse practitioner initially considered hand, foot, and mouth disease as the primary differential diagnosis. However, the presentation was atypical given the isolated palmar involvement without characteristic oral lesions or pedal manifestation. Parents expressed concern that the presentation differed from their previous experience with hand, foot, and mouth disease in their other child. Additional considerations raised during discussion included Kawasaki disease, though the absence of fever made this less likely.

Final Diagnosis

Probable atypical hand, foot, and mouth disease with isolated palmar manifestation

Treatment Plan

Conservative management with symptomatic care was recommended. Parents were advised to monitor for fever development, worsening symptoms, or progression of the rash. Supportive care included maintaining adequate hydration, comfort measures for irritability, and appropriate diaper care for the concurrent diaper rash.

Outcome and Follow-up

Parents were counseled to return for reassessment if symptoms worsened, fever developed, or if additional concerning features appeared. Specific attention was given to monitoring for signs of Kawasaki disease given the initial presentation of palmar erythema, though this was considered unlikely without fever. Close follow-up was arranged to ensure resolution of symptoms.