Non-blanching rash in a child with EBV infection: A pediatric diagnostic puzzle

Background: Epstein Barr Virus (EBV) infection is highly prevalent worldwide and commonly presents as infectious mononucleosis in children. Although cutaneous manifestations are well described, vasculitic presentations are rare and often under-recognized. Case Presentation: We report a 10-year-old previously healthy boy presenting with 16 days of persistent fever and sore throat, unresponsive to antibiotics. On admission, he developed a non-itchy, palpable, non-blanching erythematous maculopapular rash over the face, neck, chest, and abdomen, along with exudative tonsillitis, lymphadenopathy, and splenomegaly. Laboratory findings revealed lymphocytosis with atypical lymphocytes, elevated liver enzymes, LDH, and ferritin. EBV serology confirmed acute infection. Hemophagocytic lymphohistiocytosis was ruled out. The patient was managed conservatively with supportive care, leading to complete resolution within two weeks. Discussion: Investigations concluded acute EBV infection with associated rash. The non-blanching, non-itchy, palpable, maculopapular rashes were suggestive of vasculitis with no evidence of systemic involvement in this patient. We could not have a histopathological diagnosis as his parents declined consent for a skin biopsy. Conclusion: This case highlights the rare occurrence of cutaneous vasculitis in pediatric EBV infection. It underscores the importance of clinical vigilance when biopsy is not feasible and adds to the current literature on the clinical presentation, diagnosis and management of EBV associated vasculitis in the pediatric population.

Keywords: Epstein-Barr Virus, vasculitis, maculopapular rash, pediatric