A 10-year-old girl was brought to the ED by her mother due to fever, headache, muscle aches, nausea, and a skin rash. On examination, the patient appeared ill with a temperature of 102°F (38.9°C). Numerous erythematous macules and some purpura were seen on her palms and soles. The patient was immunocompetent with an unremarkable medical history. Her mother recounted no recent travel but noted that the patient spent a day gardening with her grandmother approximately 1 week prior to the appearance of the rash and other symptoms. They lived in North Carolina. The mother wondered if this was an allergic response to contact with a toxic plant or a response to a bug bite.
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