doi:10.1111/jpc.

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IMAGES OF THE MONTH

An adolescent with chronic scaling of the lips

Question
A 10-year-old girl presented with a 1-year history of scaling and
cracking of the lips, causing significant cosmetic concern. The
clinical course was characterised by periods of exacerbation and
partial remissions, and she had moderate to severe discomfort,
especially during eating and speaking. She had been treated with
emollient creams and low-potency topical steroids, with no effec-
tive improvement. She was otherwise healthy and had a positive
family history of psoriasis.
Fig. 1 Fissuring and scalling of the lips, extending beyond vermillion border.
Her examination revealed fissures and desquamation of the
whole lips, extending beyond the vermillion border (Fig. 1). Oral
mucosa and the surrounding skin were normal and there was no Dr Joana Correia1
involvement of other skin areas. Dr Susana Machado2
Patch testing with a standard series of common allergens and Dr Manuela Selores2
dental products were negative. Departments of 1Pediatrics and 2Dermatology
What is your diagnosis? (Answer on page 315) Centro Hospitalar do Porto
Porto
Portugal

Prolonged fever in an 8-year-old boy post-Epstein–Barr virus infection

Question
A 7-year-old boy presented to a tertiary paediatric Emergency
Department with a 3-week history of fever, lethargy and loss of
appetite. He had been reviewed by his family doctor on three sepa-
rate occasions prior to presentation, and had completed a course of
oral amoxicillin with no improvement. He had no significant past
medical history, no sick contacts nor any history of recent travel.
On examination, the patient was febrile (39.1 C) and tachyp-
noeic. There were multiple small (<1 cm) non-tender lymph nodes
palpable in the posterior cervical chain, left axilla and inguinal
regions. The liver edge was palpable 4 cm below the right costal
margin, with a tippable spleen. Epstein–Barr virus serology
requested by the patient’s family doctor was consistent with acute Fig. 1 Wright–Giemsa stain of the patient’s bone marrow aspirate.
infection (positive IgM and equivocal IgG to Epstein–Barr virus viral
capsid antigen). A diagnosis of infectious mononucleosis was made. Professor Catherine Cole1,3,4,5
During admission, the patient continued to be febrile with progres- Dr Murray Princehorn6
sive anaemia and thrombocytopaenia, along with hyperferritinaemia Dr Christopher C Blyth1,2,7,8
(5480 μg/L) and hypertriglyceridaemia (3.6 mmol/L). His IgA, IgM 1
School of Paediatrics and Child Health
and IgG levels were elevated (22.4, 5.3 and 13.3 g/L respectively). University of Western Australia
Along with this, further questioning revealed an older brother who Princess Margaret Hospital
passed away from overwhelming sepsis. A bone marrow aspirate Departments of 2Infectious Diseases, 4Haematology, and 6General
was requested as part of the further investigative work-up (Fig. 1). Paediatrics
What does it show? Given this appearance and the provided investi- PathWest Laboratory Medicine, Princess Margaret Hospital
gation results, what is the likely diagnosis? (Answer on page 315) Departments of 3Haematology, 5Cancer Centre, 7Microbiology, and
8
Wesfarmers Centre for Vaccines and Infectious Diseases
Mr Amirul H Ahmad Bazlee1,2 Telethon Kids Institute, University of Western Australia
Dr Daniel Yeoh2 Perth, Western Australia
Mr Jesper Jensen3 Australia

314 Journal of Paediatrics and Child Health 53 (2017) 314–315

© 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)