A 12-month-old Somali-American boy presents to the emergency department with subjective fevers, hepatosplenomegaly, and a 1-month history of a pruritic, papulovesicular eruption that predominantly affects the extremities after mild upper respiratory tract symptoms. The rash began as “small red bumps” on the thighs that spread during 2 weeks to include all 4 extremities (Figure 1,) and scalp (Figure 2,) and a few lesions on the chest and abdomen (Figure 3 ). At that time, the boy was taken to his pediatrician, who prescribed a treatment regimen of permethrin cream for putative scabies and oral trimethoprim-sulfamethoxazole for a concern of bacterial superinfection. During the next 2 weeks the symptoms continue unabated, so the mother brought the child to the emergency department, where he is admitted for diagnostic evaluation.

The child does not take any medications, vitamins, or herbs, excluding the recently prescribed permethrin...

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