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PETECHIAE, redness in foot, positive STREP TEST. Treatment.

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My 12 year old daughter developed petechiae on Monday evening. There was a large section on her left foot and some redness on her lower legs.

On Tuesday, her pediatrician examined her and administered a blood test. Her platelets were normal as was other levels except for her WBC. It was a little low at 3.9. The pediatrician said the lower level might be the result of a virus. The blood test for mono was negative but the swab test for strep was positive. The pediatrician thought that was unusual since the WBC should be elevated for a bacterial infection. She gave her an antibiotic which she started yesterday. She has no symptoms of an illness. No fever, no congestion, no coughing, no sore throat. Her finger prick clotted normally.

She's scheduled for a follow up visit and blood test next tuesday.

I'd like to know the possible causes of the petechiae and the low WBC count.



Category: Pediatrician

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Category: ICU/ Critical Care Specialist
 27 Doctors Online

Thank you for your query at
I can understand your concerns. Your description of the rash as 'petechiae' appears to be misleading. The exact nature of the rash will become clear only if you attach a clinical photograph. I am saying this because, petechiae are a distinct group of skin lesions usually produced by a SUB-CUTANEOUS bleed either due to a low platelet count, platelet dysfunction or vasculitis (inflammation of vessel wall). In your daughter's case, all three appear unlikely. So, attaching a clinical photograph of the skin lesion will help us understand the situation better.
Secondly, your child could be having a streptococcal infection that is manifesting with skin rash. It is true that most streptococcal infections would have high-grade fever and leucocytosis. However, presence of elevated counts, though seen commonly is not a MUST in every child. Children with only skin infections may not have much fever or leucocytosis. Hence, the clinical picture is not completely against the diagnosis of a bacterial skin infection (cellulitis/ scarlet fever)
The strep throat swab test is a very sensitive and specific test for the presence of Group A streptococcus in children and is definitely reliable. Hence, there is a definite possibility that your daughter could be having a milder version of scarlet fever as children with streptococcal sore throat can develop a classical, deep red rash and a red tongue (forming the classical features of scarlet fever, which is not there in our child). However, the treatment for this condition is similar to management of a child with strep throat. There is no need for any heightened concern as long as she is receiving the appropriate antibiotics.
Having said that she should also undergo testing for dengue (which can present similarly) and any underlying immunodeficiency (primary/secondary) if there are any other clues (recurrent infections, persistently low counts, poor growth, candidal infections, etc)
Hope she gets well soon.
Dr. Saptharishi L G

Patient replied :

She's taking Cefdinir 10 ML daily for 10 days. I've attached photos of her lower legs and the top of her left foot. If you need better quaility photos, pleaselet me know and I can use a higher res camera.
Her growth seems normal. She's 5' 3-1/2". She hasn't have previous rashes. She hasn't had a mosquito bite in several weeks. What's the lag time for a reaction from dengue?
Would you suggest she see a specialist?
Thanks, Doug

Hello Doug,
I am one of the InHouse Physicians.
I checked the pictures that you sent, they are no clear. Will it be possible for you to upload a higher resolution picture if you don't mind? The specialist can't really make out anything from this image that you sent.
InHouse Physician

Patient replied :

These 3 were taken with a higher res camera. If they aren't acceptable, can you suggest a method of getting better photos? Thank you, Doug These photos might be a little better. We took them with a microscope camera

Thank your providing the clinical photographs of your daughter. They appear to indicate the presence of an erythematous scarlatiniform rash. This could be consistent with a streptococcal infection with concomitant rash. Treatment with Cefdinir could be considered appropriate. The dosage also seems to be appropriate (assuming your daughter weighs around 30-40 kg)
And based on your description, dengue as well as immunodeficiency disorders appear unlikely.
Complications of scarlet fever are rare in children who are treated with antibiotics. However, one should watch out for rheumatic fever, glomerulonephritis, etc. So it would be important to stay in touch with the concerned infectious disease specialist to make sure that these complications are not missed, however rare they may appear to be.

Dr. Saptharishi L G
Category: ICU/ Critical Care Specialist
Senior Residency: DM,  Pediatric Critical Care, PGIMER

Residency: MD, Pediatrics, Postgraduate Medical Education & Research (PGIMER), Chandigarh, 2013

Internship: JIPMER, 2009

Medical School: MBBS, Jawaharlal Institute of Post-graduate Medical Education & Research (JIPMER), Puducherry, 2008
Dr. Saptharishi L G and 4 other Medical Specialists are ready to help you

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