Fever and rash in children

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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

• [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
• In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
• In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

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) .

Common types of rashes encountered in clinical practice :

Type of Rash/Lesion	Description
Macule	flat, circumscribed, usually <1cm in diameter
Papule	raised/elevated lesion <1cm in diameter
Maculopapular	combination of both macules and papulus
Nodule	papule in deeper dermis or subcutaneous tissue
Pustule	circumscribed raised lesion containing purulent material
Vesicle	circumscribed elevated skin lesion usually <1cm containing fluid
Bulla	Bigger vesicle (>1cm and containing fluid)
Petechiae	non-blanching pinpoint unraised spots usually measuring <2mm in size
Purpura	non-blanching papules or macules due to extravasation of RBCs. Vary between 2mm-1cm in size
Ecchymoses	non-blanching lesions usually measuring larger than 1cm

Classification of febrille rashes :

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-Schőnlein Purpura (HSP)
Blanching rash	a. Kawasaki disease b. Juvenile Rheumatoid Arthritis c. Juvenile Dermatomyositis
Vesicular or bullous lesions	a. Erythema multiforme b. Steven-Johnson-Syndrome (SJS) and Toxic Epridermal 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 b. Varicella/Chickenpox
Sandpaper rash	a. Scarlet fever
Viral syndromes	a. Measles (Rubeola) b. Rubella (German measles) c. Erythema infectiosum (Parvovirus B-19) 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 b. Blastomycosis c. Coccidiodomycosis d. Histoplasmosis e. Colorado Tick Fever f. Lyme disease g. Relapsing fever h. Colorado Tick Fever

Pathophysiology

• The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Infectious	Disease	Causative Organism	Non-Infectious	Disease
Viral	Measles German Measles Erythema infectiosum Roseola infantum Herpangina Hand-foot-and-mouth disease Molluscum contagiosum Chickenpox	Rubeola Rubella Parvovirus B19 Human Herpes Virus 6 & 7 Coxsackie virus Coxsackie virus Poxvirus Varicella Zoster virus	Immune-mediated/Autoimmune	Kawasaki Disease Henoch-Schőnlein Purpura Juvenile Rheumatoid Athritis Juvenile Dermatomyositis
Bacterial	Meningococcemia	Neisseria meningitidis Hemophilus influenzae Streptococcus pneumoniae	Adverse drug reactions	Erythema multiforme SJS TEN
	RMSF	Rickettsia rickettsii
	HUS	Enterohemorrhagic E.coli (EHEC)
	Scarlet Fever	Streptococcus pyogenes (Group A Streptococci, GAS)
	Disseminated gonococcal disease in adolescents	Neiserria gonorrhoea
	SSSS TSS	Staphylococcus aureus
	Lyme disease	Borrelia burgdorferi
	Relapsing fever	Borrelia recurrentis
Protozoan	Babesiosis	Babesia microti
Fungal	Histoplasmosis Blastomycosis Coccidiodomycosis Paracoccidiodomycosis	Histoplasma capsulatum Blastomyces dermatitidis Coccidioides immitis Paracoccidioides brasiliensis

Differentiating [disease name] from other Diseases

For further information about the differential diagnosis, click here.

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• [Disease name] is more commonly observed among patients aged [age range] years old.
• [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

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:

• Group 1- Children presenting with severe illness and require immediate intervention based on history and physical examination
• 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 watery 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
• 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
    • Blood cultures
    • Stool and urine microscopy/culture/sensitivity
    • Antibody and PCR assays- RMSF
    • Skin biopsy of lesions in HSP showing leukocytoclastic vasculitis, immunofluorescence studies

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].