A 14-month-old girl presented with acute onset erythematous skin eruption on her body, following an episode of upper respiratory tract infection. On examination, the child was febrile and the vitals were stable. There were multiple, non-tender, purpuric targetoid lesions studded with vesicles on her face, pinna, extremities and buttocks. The mucosa and the trunk were spared. There was mild non-pitting edema over the upper extremities and the face. Systemic examination was normal. Routine blood examination, coagulation profile, renal function tests, blood culture, and urine analysis were normal, except for mild leucocytosis (total leukocyte count 12,600 mm³). Histopathlogical examination from the lesion showed features of leucocytoclastic vasculitis. A diagnosis of Acute hemorrhagic oedema of infancy (AHEI) was made. Fever subsided in two days and the skin lesions completely subsided within the next two weeks.

Fig. 1 (a) Purpuric targetoid lesions on face; (b) Close-up view of the lesion.

AHEI is a benign, self-limiting leucocytoclastic vasculitis generally affecting children under the age of 2 years. An upper repiratory illness usually precedes the sudden onset of red macules or urticarial skin lesions. AHEI lesions vary from 0.5 to 4 cm in size occasionally becoming confluent to annular or targetoid purpuric lesions. It mainly affects the face and extremities, sparing the trunk, and often accompanied by non-pitting edema.

Differential diagnosis of AHEI include Henoch Schonlein purpura (older age, smaller lesions, facial sparing, systemic involvement, slow resolution, meningococcemia (central necrosis), erythema multiform (three concentric color zones), Sweet’s syndrome (erythematous blue or violet papules, plaques, or nodules often with a pseudo-vesicular appearance), urticarial vasculitis (absence of target-like lesions; purpuric spots visible on diascopy, hyperpigmentation on healing), and fixed drug eruptions (round or oval sharply delineated erythematous plaques with central blister or necrotic area).