Fever and rash in children: Difference between revisions
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==Treatment== | ==Treatment== | ||
===Medical therapy=== | ===Medical therapy=== | ||
*[[Triaging]] kids who present with [[fever]] and [[rash]] into 3 groups on basis of early [[symptoms and signs]] is essential for making prompt [[diagnosis]] and administering possible treatment regimen. These groups are: | |||
*Children presenting with severe illness necessitating immediate intervention. This is especially true for the non-[[blanching]] [[lesions]]. | |||
* | *Children presenting with [[viral]] [[syndromes]] which are easily recognized and require [[symptomatic]] [[treatment]] and reassurance. | ||
* | *Children presenting [[undifferentiated]] [[rashes]] which could be [[benign]] or an unusual presentation of severe illness. | ||
* | *The first group are usually managed in the [[hospital]] with [[Intravenous fluids|intravenous fluid]] [[therapy]] with/without [[Vasopressors|vasopressor]], initiation of [[empirical]] [[antibiotics]] while awaiting [[Culture collection|culture]] results. Third generation [[Cephalosporins|Cephalosporin]] are first line for [[meningococcemia]]. [[Doxycycline]] is drug of choice for [[Rocky Mountain spotted fever|RMSF]]. [[Treatment]] for [[Hemolytic-uremic syndrome|HUS]] is supportive with a [[consultation]] to the [[Nephrologist]] to manage [[renal failure]]. | ||
*The second group as earlier mentioned is managed conservatively with measures like [[antipyretics]], fluid therapy, [[antihistamines]] to soothe the patient and reassurance to care-givers. Most recover without any [[complications]]. | |||
*Majority of children in this group have [[benign]] [[viral]] illness that resolves spontaneously. Others may have unusual 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 drug|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. | |||
In general, most [[bacterial diseases]] are treated with the appropriate [[antibiotics]], [[Antifungal drug|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. | |||
===Surgery=== | ===Surgery=== | ||
Revision as of 19:17, 24 September 2020
|
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.
Classification
- Febrile rashes can be classified based on:
- Morphology (maculopapular, pustular, vesicular, etc)
- Distribution of spread (systemic and localized
- Pattern of occurrence (acute and chronic)
- Cause (infectious and non-infectious) [1]
- Types of rashes found among pediatric patients include the following: macules, papules, nodules, pustules, vesicles, bullae, petechiae, purpura and ecchymoses. [1]
- Classification of febrille rashes based on rash morphology are as follows:[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
- It is understood that infectious processes accounts for up to 74% of fever in hospitalized patients, the remainder being caused by malignancy, ischemia and drug-related reactions. [6]
- Fever results when exogenous (micro-organisms) and endogenous (Interleukin[IL]-1, IL-6 and Tumor Necorsis Factor[TNF]-α) pyrogens interact with the Organum Vasculosum of the Lamina Terminalis (OVLT). [6]
- The OVLT is highly vascular organ located in the anterior hypothalamus, lacking the Blood-Brain-Barrier (BBB) thus easily accessible to pyrogens. The resultant increased production of Prostaglandin E2 (PGE2) results in raised body temperature. [6]
- Another mechanism is by production of PGE2 by Lipopolysaccharide (LPS) on gram negative bacteria and by the Toll-like receptor cascade. [6]
- Skin lesions (rash) could be primarily vascular or from infection spread to tissues (e.g. skin). [7]
- The first step in the formation of a skin lesion/rash is localization of the micro-organism in the blood vessel walls. [7]
- A macule forms from sustained local dilation of subpapilary dermal blood vessels.
- Edema with infiltration of cells turns a macule to papule.
- Primary epidermal involvement results in vesicles, ulcers and scabs and secondary epidermal changes can lead to desquamation and pigment changes. [7]
Causes
| 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 |
Epidemiology and Demographics
Age
Race
Gender
- No known gender predilection.
Most children become susceptible to some of the diseases from 6 months of age when maternal antibodies begin to wane. [8]
Risk Factors
- Common risk factors for the development of diseases that present with fever and rash include:
- Contact with ill individuals
- Poor/depressed immunity
- Lack of vaccination
- Very young age (6 months-12 months)
- Poor hand washing habits
Natural History, Complications, and Prognosis
Natural History
- The symptoms of diseases associated with fever and rash usually develop in the first few days from contact. The stages/phases of most infectious processes include the:
- Incubation period (between exposure to an infection and the appearance of the first symptoms).
- Prodromal phase (period of early symptoms of a disease)
- Illness (characteristic symptoms of the disease appear at this stage)
- Decline and
- Convalescence
Complications
- Common complications of diseases presenting with fever and rash include:
- Febrille seizures
- Rhabdomyolysis
- Shock (septic or hypovolemic)
- Disseminated Intravascular Coagulation (in Meningococcemia)
- Reye syndrome (especially in children that have been given aspirin).
Prognosis
- Prognosis is generally excellent for viral syndromes. Prompt diagnosis, treatment and close follow-up of patients presenting with other causes of fever and rash also results in good prognosis.
Diagnosis
- Rapid clinical diagnosis is necessary in severe cases to begin immediate empiric therapy while awaiting test results.
Symptoms
- Besides fever and rash, additional symptoms may include:
- The above additional symptoms are usually seen in the prodromal phase of most infectious diseases. Other symptoms are:
- Recent upper respiratory tract infections or diarrheal illness
- Earpain
- Pruritus (which could be severe in drug related rashes)
- Poor appetite
- Headaches
- Diarrhea
- Pallor
- Pains in certain body areas (arthritis)
- Important details in the history include:
- Onset and progression of symptoms
- Site of the rash(central or peripheral)
- Relation with season(s)
- Travel history
- tick bite(s)
- Contact with an ill person or animal
- Medication history (most especially sulfonamides, NSAIDs and anticonvulsants)
- Exposure to forest or other natural environment
- Also important to evaluate the immune status of the patient
Physical Examination
- Findings on examination include:
- Illness severity
- Type of rash, its location and distribution
- Lymphadenopathy
- Conjuctival, oral and genital changes
- Nuchal rigidity (especially in older kids)
- Nikolsky's sign
- Areas of tenderness (e.g. at the joints)
- Hepatomegaly, splenomegaly
- Hypotension
- Tachycardia
Laboratory Findings
- Laboratory findings needed to support diagnosis or determine illness severity of some diseases are as follows:
- Complete blood count with differentials which might reveal anemia, thrombocytopenia, elevated white blood cell count.
- Factor assays showing low coagulation factors in severe Meningococcemia with Disseminated Intravascular Coagulation (DIC)
- Serum chemistries: electrolyte imbalance in (HUS, Meningococcemia)
- Labs to isolate offending organisms in infectious diseases for targeted antibiotics regimen are;
- 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 [9]
- Skin biopsy of lesions in HSP showing leukocytoclastic vasculitis
- Immunofluorescence
- Immunohistochemistry for diagnosing Systemic mycoses (fungal infections related to certain geographical areas). [10]
- 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. [11]
Electrocardiogram
- There are no ECG findings associated with fever and rash.
X-ray
- Might be useful in managing severely ill individuals to look for complications but not routinely needed to make diagnosis.
Echocardiography or Ultrasound
- There are no echocardiography findings associated with fever and rash but can be used 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
- There are no MRI findings associated with fever and rash.
Other Imaging Findings
- There are no other imaging findings associated with fever and rash in children.
Treatment
Medical therapy
- Triaging kids who present with fever and rash into 3 groups on basis of early symptoms and signs is essential for making prompt diagnosis and administering possible treatment regimen. These groups are:
- Children presenting with severe illness necessitating immediate intervention. This is especially true for the non-blanching lesions.
- Children presenting with viral syndromes which are easily recognized and require symptomatic treatment and reassurance.
- Children presenting undifferentiated rashes which could be benign or an unusual presentation of severe illness.
- The first group are usually managed in the hospital with intravenous fluid therapy with/without vasopressor, 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.
- The second group as earlier mentioned is managed conservatively with measures like antipyretics, fluid therapy, antihistamines to soothe the patient and reassurance to care-givers. Most recover without any complications.
- Majority of children in this group have benign viral illness that resolves spontaneously. Others may have unusual 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.
Surgery
- Surgical intervention is not recommended for the management of fever and rash in children.
Prevention
- Effective measures for primary prevention of fever and rash in children may include:
- Vaccination done in a timely manner can prevent occurrence of many childhood illnesses presenting with fever and rash such as the viral symdromes. [12]
- Hand washing frequently and thoroughly with soap and water.
- Sneeze and cough into elbows and/or tissues(which should be thrown away).
- Avoid contact with infected individuals and contaminated surfaces.
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
- ↑ 6.0 6.1 6.2 6.3 Walter EJ, Hanna-Jumma S, Carraretto M, Forni L (2016). "The pathophysiological basis and consequences of fever". Crit Care. 20 (1): 200. doi:10.1186/s13054-016-1375-5. PMC 4944485. PMID 27411542.
- ↑ 7.0 7.1 7.2 Mims CA (1966). "Pathogenesis of rashes in virus diseases". Bacteriol Rev. 30 (4): 739–60. PMC 441013. PMID 5342519.
- ↑ 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.