A 12-year-old girl presented with a one-week history of fever associated with jaundice, vomiting and skin rash on the fifth day of illness. She denied any abdominal pain, diarrhoea, history of recent shell-fish or traditional medication ingestion. On examination, she appeared jaundice, and there was sandpaper-like rash on the trunk and extremities (A). Laboratory investigations revealed severe transaminitis (AST 849 U/L, ALT of 1092 U/L) and predominantly direct hyperbilirubinaemia. Hepatitis A IgM was reactive whereas leptospirosis, hepatitis B and C serology were non-reactive. The antistreptolysin O titre and throat swab culture were negative. Ultrasound of the hepatobiliary system demonstrated normal liver parenchyma without sonographic evidence of biliary obstruction. She was admitted for intravenous fluid and symptomatic therapy. She remained well with improving transaminitis, and did not exhibit any signs of liver failure. She was discharged after 5 days of hospital stay. The rash disappeared and liver function test normalized during a followup review 2 weeks post-discharge. Many types of skin rashes can occur as a part of the serum sickness-like prodrome of acute viral hepatitis which is thought to be due to immune complex deposition. An evanescent rash was reported to be present in 14% of patients with acute hepatitis A. Cutaneous vasculitis associated with hepatitis A can appear as an erythematous maculopapular eruption affecting the buttocks and lower extremities. Scarlatiniform rash has not been reported previously in hepatitis A infection. Clinicians should be alert to this rare extrahepatic manifestation of hepatitis A infection when encountering patients with skin rash and severe transaminitis.

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Corresponding author
Chee Yik Chang, Department of General Medicine, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia (ccyik28@gmail.com)