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Revision as of 02:15, 22 September 2020
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Fever and rash in children Microchapters |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ifeoma Anaya, M.D.[2]
Synonyms and keywords: Fever and rash in kids
Overview
Fever and skin rash are very common symptoms seen in pediatric populations both in clinic and hospital settings. Disease states associated with these symptoms are varied and can range from benign to extremely severe illness requiring prompt intervention in the emergency room or even ICU. Therefore, a vast knowledge of these disease states is very important as oftentimes, diagnosis is mainly clinical.
Historical Perspective
Dependent on actual diagnosis.
Classification
Febrile rashes can be classified based on morphology (maculopapular, pustular, vesicular, etc); based on distribution of spread (systemic and localized); based on pattern of occurrence (acute and chronic); based on the cause (infectious and non-infectious) [1].
Common types of rashes encountered in clinical practice are macules, papules, nodules, pustules, vesicles, bullae, petechiae, purpura and ecchymoses. [1]:
Classification of febrille rashes [2] [3] [4] [5]:
| Fever + Rash Morphology | Disease |
|---|---|
| Non-blanching lesions (Petechiae, Purpura and Ecchymoses) | a. Meningococcemia
b. Rocky Mountain Spotted Fever (RMSF) c. Hemolytic Uremic Syndrome (HUS) d. Henoch-Schonlein Purpura (HSP) |
| Blanching rash | a. Kawasaki disease
b. Juvenile Rheumatoid Arthritis c. Juvenile Dermatomyositis |
| Vesicular or bullous lesions | a. Erythema multiforme
b. Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) c. Staphylococcal Scalded Skin Syndrome (SSSS) d. Disseminated gonococcal disease in adolescents e. HSV I & II |
| Umbilicated papules and pustules | a. Molluscum contagiosum |
| Sandpaper rash | a. Scarlet fever |
| Viral syndromes | a. Measles (Rubeola)
b. Rubella (German measles) c. Erythema infectiosum (Parvovirus B19) d. Herpangina (Coxsackie) e. Hand-foot-and-mouth disease (Coxsackie) f. Roseola infantum (Human Herpes Virus types 6 or 7) |
| Limited to certain geographical areas | a. Babesiosis
e. Lyme disease g. Colorado Tick Fever |
Pathophysiology
This is strongly dependent on the cause of the disease. Whether infectious or non-infectious, drug-related eruptions or immune-mediated.
Causes
| Causes of fever and rash | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Infectious | Non-infectious | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Immune-mediated/Autoimmune | Drug-related eruptions | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Viral | Bacterial | Protozoan | Fungal | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Infectious | Disease | Causative Organism |
|---|---|---|
| Viral | Measles | Rubeola
Human Herpes Virus 6 & 7 Varicella Zoster virus |
| Bacterial | Meningococcemia |
Neisseria meningitidis |
| RMSF | Rickettsia rickettsii | |
| HUS | Enterohemorrhagic E.coli (EHEC) | |
| Scarlet Fever | Streptococcus pyogenes (Group A Streptococci, GAS) | |
| Disseminated gonococcal disease in adolescents | Neisseria gonorrhoea | |
| SSSS | Staphylococcus aureus | |
| Lyme disease | Borrelia burgdorferi | |
| Relapsing fever | Borrelia recurrentis | |
| Protozoan | Babesiosis | Babesia microti |
| Fungal | Histoplasmosis | Histoplasma capsulatum |
| Non-Infectious | Disease |
|---|---|
| Immune-mediated/Autoimmune | Kawasaki Disease
Juvenile Dermatomyositis |
| Drug-related eruptions | Erythema multiforme |
Differential Diagnosis
Fever and rash are symptoms of the several diseases listed above. Other diseases associated with fever and rash include:
- Secondary syphillis
- Erythema nodosum
- Infectious mononucleosis rash associated with amoxicillin
- Pityriasis rosea
- Impetigo
- Atopic dermatitis
- Multisystemic Inflammatory Syndrome in Children (MIS-C), etc.
Epidemiology and Demographics
Most children become susceptible to some of the diseases from 6 months of age when maternal antibodies begin to wane [6]. Gender and race predilections varies greatly depending on the disease.
Risk Factors
Risk factors are specific to actual disease. This can include contact with ill individuals, poor/depressed immunity, age, etc.
Natural History, Complications and Prognosis
This depends on the actual disease. Majority of patients do however recover without complications when adequate treatment is promptly instituted.
Diagnosis
In severe cases, quick clinical diagnosis is necessary in order to institute immediate empiric therapy while awaiting test results. It is therefore important to have detailed knowledge of symptoms and signs of the common diseases in kids that present with fever and rash. A practical approach to triage kids who present with fever and rash for near accurate diagnosis is to divide them into 3 groups on basis of initial presenting symptoms:
- Group 1- Children presenting with severe illness and require immediate intervention based on history and physical examination. This is especially true for the non-blanching lesions.
- Group 2- Children who present with recognizable viral syndromes that requires symptomatic treatment and reassurance.
- Group 3- Children with undifferentiated rashes which could either be benign or atypical presentation of serious illness.
Symptoms
Besides fever and rash, other symptoms of possible diseases includes the following:
- runny nose
- cough
- sore throat
- history of upper respiratory tract infection or diarrheal illness
- earache
- red eyes (conjunctivitis)
- pruritus (which could be severe in drug related rashes)
- poor appetite
- headaches
- diarrhea
- pallor
- irritability
- pains in certain body areas (arthritis)
Important details to watch out for in the history include:
- time of onset and progression of symptoms
- location of the rash(central or peripheral) and the rate of emergence
- seasonal occurrence
- recent travel
- any tick bite(s)?
- contact with an ill individual or animal
- detailed medication history (especially sulfonamides, NSAIDs and anticonvulsants)
- exposure to forest or other natural environment
- also important to evaluate the immune status of the patient
Physical Examination
In addition to symptoms already listed above, additional findings on examination include;
- state of the child (how ill?)
- rash morphology and its location/distribution
- lymph node enlargement
- conjuctival, oral and genital findings
- nuchal rigidity (in older kids)
- Nikolsky's sign
- tenderness (at the joints)
- hepatomegaly, splenomegaly or both
- tachycardia
- hypotension
Laboratory Findings
Laboratory tests for the various diseases is largely dependent on etiology. They are needed mostly to support diagnosis.
- Non-blanching lesions:
- Complete blood count with differentials- may show anemia, thrombocytopenia, elevated white blood cell count.
- Factor assays- depleted coagulation factors in severe meningococcemia with Disseminated Intravascular Coagulation (DIC)
- Serum metabolic panel: electrolyte derangements (HUS, Meningococcemia)
- Other labs to isolate offending organism in order to switch to appropriate antibiotics include;
- Nasal/throat swab for rapid strep test and/or culture
- Blood cultures
- Stool and urine microscopy/culture/sensitivity
- Cerebrospinal fluid (CSF) analysis
- Antibody and PCR assays- RMSF [7]
- Skin biopsy of lesions in HSP showing leukocytoclastic vasculitis
- Immunofluorescence
- Immunohistochemistry of tissue specimens is an invaluable tool in diagnosing systemic mycotic infection (fungal infections related to certain geographical areas) [8].
- The viral syndromes, Varicella, Molluscum contagiosum, Lyme disease, the Immune-mediated vasculitis and Drug related eruptions rely heavily on a good history and physical examination findings to make a diagnosis.
- Peripheral thick and thin blood smear shows Babesia microti [9].
Electrocardiogram
May be useful in management of very severe cases of meningococcemia or HUS requiring hospital admission to monitor effect of electrolyte derangements on the heart.
X-ray
Might be useful in managing severely ill individuals to look for complications but not routinely needed to make diagnosis.
Echocardiography or Ultrasound
To monitor for coronary aneurysm in a patient with Kawasaki disease.
CT scan
There are no CT scan findings associated with any of the diseases.
MRI
Not routinely used to make diagnosis.
Other Imaging Findings
There are no other imaging findings associated with outlined disease states.
Treatment
- Group 1: managed in the hospital with aggressive intravenous fluid therapy and vasopressor support, initiation of empirical antibiotics while awaiting culture results. Third generation Cephalosporin are first line for meningococcemia. Doxycycline is drug of choice for RMSF. Treatment for HUS is supportive with a consultation to the Nephrologist to manage renal failure.
- Group 2: Viral syndromes are managed conservatively with measures like antipyretics, fluid therapy, antihistamines to soothe the patient and reassurance to care-givers. Most recover without any complications.
- Group 3: Vast majority of children in this group have benign viral illness which resolves spontaneously. Others may have atypical presentations of serious illness and would require close monitoring with further evaluation and easy access to care. May be sometimes needful to admit.
In general, most bacterial diseases are treated with the appropriate antibiotics, antifungal therapy for diseases of fungal origin, viral syndromes tend to resolve spontaneously with symptomatic treatment, drug related eruption require cessation of offending drug with adequate treatment of symptoms and fluid therapy.
Prevention
- Vaccination done in a timely manner can prevent occurrence of many childhood illnesses presenting with fever and rash [10].
- Hand washing
- Avoid contact with individuals who are ill.
References
- ↑ 1.0 1.1 Kang JH (2015). "Febrile Illness with Skin Rashes". Infect Chemother. 47 (3): 155–66. doi:10.3947/ic.2015.47.3.155. PMC 4607768. PMID 26483989.
- ↑ https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-1
- ↑ https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-2
- ↑ https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-3
- ↑ https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-4
- ↑ Tesini BL, Epstein LG, Caserta MT (2014). "Clinical impact of primary infection with roseoloviruses". Curr Opin Virol. 9: 91–6. doi:10.1016/j.coviro.2014.09.013. PMC 4267952. PMID 25462439.
- ↑ McQuiston JH, Wiedeman C, Singleton J, Carpenter LR, McElroy K, Mosites E; et al. (2014). "Inadequacy of IgM antibody tests for diagnosis of Rocky Mountain Spotted Fever". Am J Trop Med Hyg. 91 (4): 767–70. doi:10.4269/ajtmh.14-0123. PMC 4183402. PMID 25092818.
- ↑ Jensen HE, Schønheyder HC, Hotchi M, Kaufman L (1996). "Diagnosis of systemic mycoses by specific immunohistochemical tests". APMIS. 104 (4): 241–58. doi:10.1111/j.1699-0463.1996.tb00714.x. PMID 8645463.
- ↑ Parija SC, Kp D, Venugopal H (2015). "Diagnosis and management of human babesiosis". Trop Parasitol. 5 (2): 88–93. doi:10.4103/2229-5070.162489. PMC 4557163. PMID 26629450.
- ↑ Fölster-Holst R, Kreth HW (2009). "Viral exanthems in childhood--infectious (direct) exanthems. Part 1: Classic exanthems". J Dtsch Dermatol Ges. 7 (4): 309–16. doi:10.1111/j.1610-0387.2008.06868.x. PMID 18803578.