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strawberry tongue. Pastia lines, bright red, orange, or even hemorrhagic lines, can
occasionally be seen in the axillae or antecubital fossa. The rash generally lasts 3
to 5 days, followed by brownish discoloration and peeling of the skin as small
flakes to entire casts of the digits. A rapid streptococcal test or throat culture
confirms infection.
Epstein–Barr Virus
Between 5% and 15% of patients with Epstein–Barr viral infection, otherwise
known as infectious mononucleosis, will have an erythematous maculopapular
eruption. Infection in young children is usually asymptomatic or so mild that
diagnosis is not sought. Older patients between 15 and 25 years of age are more
likely to present for evaluation. Fifty percent to 100% of patients with infectious
mononucleosis develop a maculopapular rash after receiving concurrent
ampicillin or amoxicillin-containing antibiotics—most commonly for an incorrect
diagnosis of streptococcal pharyngitis.
The illness begins insidiously with headache, malaise, and fever, followed by
sore throat, membranous tonsillitis, and lymphadenopathy. Splenomegaly is
common. The exanthem occurs within 4 to 6 days as a macular or maculopapular
morbilliform eruption most prominent on the trunk and proximal extremities. An
enanthem consisting of discrete petechiae at the junction of the hard and soft
palate occurs in approximately 25% of patients.
Diagnosis is often presumed clinically but may be supported by an absolute
increase in atypical lymphocytes or a positive heterophile antibody (monospot)
test (obtained after the first week of symptoms), or may be confirmed by
serology. The heterophile antibody test is less sensitive in children younger than 4
years of age. The illness is most commonly self-limited, requiring no therapy, but
due to the frequency of associated splenomegaly, affected children should not be
allowed to participate in contact sports until fully recovered and the spleen is no
longer palpable.
Mycoplasma Infections
Infections with Mycoplasma pneumoniae may cause morbilliform rashes in up to
15% of cases. The classic clinical presentation is of a child with malaise, lowgrade fever, and prominent cough. The cough is initially nonproductive but may

become productive, particularly in older children, and may persist for 3 to 4
weeks. Physical examination may reveal bilateral rales.
Diagnosis is suggested by mycoplasma PCR of the sputum or by IgM or IgG
titers of the blood. Erythromycin, clarithromycin, or azithromycin are the