Emergency Medicine Case Challenge: A Young Girl With Discolored Feet, Facial Swelling, and Cough

Melanie Malloy, MD, PhD; Sage W. Wiener, MD


February 09, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 16-month-old girl is brought to the emergency department (ED) by her mother because of 10 days of dry cough and facial swelling. The patient has also been more irritable than usual and has had a decrease in appetite. The mother reports subjective fever but has not taken the patient's temperature. The patient returned from southern Mexico 2 weeks ago, where she had spent 1 week visiting relatives. The mother denies any sick contacts, runny nose, diarrhea, and vomiting. She also states that the patient's hands and feet have recently started to look irritated.

The patient was born by spontaneous vaginal delivery at 39 weeks' gestation with no neonatal intensive care unit (NICU) admission. She is up to date on her vaccinations but has not yet had her 12-month vaccines because the family recently moved from Texas and has not established a primary care doctor. The patient lives in a newly constructed apartment building with her parents and two school-aged siblings. No mold is present in the apartment.

The father, a construction worker, is a tobacco smoker but does not smoke inside the home. The mother stays home to care for the patient. The patient eats a varied diet and breastfeeds twice a day. She speaks approximately 50 words. She has no allergies to foods or medications. Family history is significant for breast cancer in the maternal grandmother and hypertension and diabetes in the paternal grandparents.

The patient has not had any surgeries. The patient has not been exposed to any new food, drinks, or medications. When asked about any other potential exposures, the mother mentions that she has recently started using a skin cream she purchased in Mexico for lightening freckles and that she has used it occasionally on a birthmark on the child's chest.


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