Fever and rash in children
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) [1].
Common types of rashes encountered in clinical practice [1]:
| 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 [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-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
| Causes of fever and rash | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Infectious | Non-infectious | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Immune-mediated/Autoimmune | Drug-related eruptions | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Viral | Bacterial | Protozoan | Fungal | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Infectious | Disease | Causative Organism |
|---|---|---|
| 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 |
| Bacterial | Meningococcemia |
Neisseria meningitidis
Hemophilus influenzae Streptococcus pneumoniae
|
| 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 |
| Non-Infectious | Disease |
|---|---|
| Immune-mediated/Autoimmune | Kawasaki Disease
Henoch-Schönlein Purpura Juvenile Rheumatoid Arthritis Juvenile Dermatomyositis |
| Drug-related eruptions | Erythema multiforme
SJS TEN |
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 for rapid strep test and/or culture
- Blood cultures
- Stool and urine microscopy/culture/sensitivity
- Cerebrospinal fluid (CSF) analysis
- Antibody and PCR assays- RMSF [6]
- Skin biopsy of lesions in HSP showing leukocytoclastic vasculitis
- Immunofluresecnce
- Immunohistochemistry of tissue specimens is an invaluable tool in diagnosing systemic mycotic infection (fungal infections related to certain geographical areas) [7].
- 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 [8].
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
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
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 empiric antibiotics while awaiting culture results.
Third generation Cephalosporins 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. Most recover without any complications.
- Group 3:
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].
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
- ↑ 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.