Walking Pneumonia with Urticarial Vasculitis

REPORTreduced air entry and crepitations over the right infrascapular area.Other systems were unremarkable.Investigations (Fig. 2 and Table 1) revealed mild anemia (Hb 10.2 gm/dL), neutrophilia (64%), elevated C-reactive protein (CRP) of 48 mg/ dL, and erythrocyte sedimentation rate (ESR) of 57 mm/hr.Renal function, serum electrolytes, and blood and urine cultures were unremarkable.A chest X-ray on day 1 (Fig. 2A) showed right middle-zone consolidation.The child was started on broadspectrum antibiotics as per institutional protocol (intravenous ceftriaxone) for pneumonia.However, over 48 hours, the condition worsened with persistent high-grade fever, rising inflammatory parameters, worsening pneumonia, and the rash changing in distribution from all over the trunk to predominantly bilateral lower limbs.The antibiotics were therefore escalated to piperacillin-tazobactam. IntroductIonOne of the most frequent causes of community-acquired pneumonia (CAP) in children aged 10-17 is walking pneumonia, which is brought on by Mycoplasma pneumoniae (prevalence: 23%), 1 Lower respiratory tract infections affect 21.3% of children aged 2-4 years, 41.3% of children aged 5-7 years, and nearly 60% of children aged 7 years and beyond. 2 The rate of morbidity rises with age.Attack rates within families are high, with transmission rates of 40 to >80% for adult and child household contacts. 1The incubation period is approximately 14-21 days.Approximately 30% of patients have cutaneous symptoms.The most frequent cutaneous symptoms include exanthematous skin rash (8-33%), urticaria (7%), subacute nodular migratory panniculitis (8%), anaphylactoid purpura, erythema multiforme, Stevens-Johnson syndrome (1-5%), and cutaneous leukocytoclastic vasculitis. 3 case descrIptIonA previously well-immunized-for-age, and developmentally normal 9-year-old boy presented with complaints of highgrade fever with chills for 5 days and cough for 3 days.On day 3 of fever, he was treated at a private clinic with amoxicillin in view of granular pharyngitis.The child developed a widespread urticarial maculopapular rash (Fig. 1) on the 5th day of fever.On assessment, he was febrile (temperature 104F), tachycardic (130/min), and tachypneic (28/min).He had a maculopapular rash that was erythematous and nonpruritic, distributed over the trunk, bilateral upper limbs, and lower limbs.He also had bilateral eye congestion.On systemic examination, bronchial breath sounds were heard in the right inframammary area with