Fever and rash resident survival guide (pediatrics)

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Resident
Survival
Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Eman Alademi, M.D.[2]

Synonyms and keywords:
Fever:

Frenzy,Temperature, Feverishness, Heat, Ferment, Pyrexia,

Excitement, Agitation, Febrile, Feverish, Furor, Sweat, Ecstasy, Febricity, Hyperthermia.

Rush:

Reckless, Impetuous, Impulsive, Hasty, Overhasty, Foolhardy, Incautious, Precipitate, Precipitous, Premature, Careless, Heedless, Thoughtless.

Fever and rash resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Fever with rash is a common symptom redundancy in patients presenting to clinicians' offices and emergency departments. Skin manifestations may provide the only early clue to an underlying infection, may be the hallmark of contagious disease, and/or may be an early sign of a life-threatening infection or serious noninfectious disorder. The differential diagnosis of fever and rash is extremely broad, but this symptom complex show an fortuity for the exacting clinician to start a probable etiology through a careful history and physical examination.

A systematic method is crucial for starting a timely diagnosis, determining early therapy when appropriate, and considering isolation of the patient if necessary. The treatment must to be belonging to euch cause specifeclly.

and the most important part is the advice that patient have to be aware of fever and rush diseases, to avoid the severity of the fever and rush side effect.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes[20]

FIRE: Focused Initial Rapid Evaluation

The diagnostic approach to the child patient with fever and rash should focus on the appearance of the rash and the detailed epidemiologic history[37][38][39]


Season[40][41]

Geography

Incubation period

Exposure history[42][43][44][45][46]

Arthropod exposures[47][48][49][50][51]

Medication history[52]

Immunization history[53][54][55][56]

Sexual history[57][58][59]

Immunocompetence of the host[60][61]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Differential diagnosis of fever and rash based on the accompanying symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arthritis/arthralgia
 
 
Desquamation
 
 
 
 
 
 
 
Lymphadenopathy
 
 
 
 
 
 
 
Enanthems
 
Ulcerative/vesicular stomatitis
 
Palm-soul involvement
 
Rash predominantly on extremities
 
Pulmonary infiltrations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Generalized
 
Hilar
 
Cervical
 
Inguinal
 
 
 
 
 
 
 


Differential diagnosis of fever and rash based upon accompanying signs:

Arthritis or arthralgia

Acute meningococcemia

Allergic purpura

Disseminated gonoccal

Erythema marginatum(acute rheumatic fever)

hepatitis B virus, prodromal phase.

lyme disease

parvovirus B19

reiter's syndrom

rocky mountain spotted fever

roseola (especially in adults)

rubella

serum sickness

stills disease

systemic lupus erythematous

Desquamation

Arcanobacterium haemolyticum infection

Drug hypersensitivity

Graft-versus-host reaction

Kawasaki syndrome

Measles

Rocky Mountain spotted fever

Scarlet fever

Staphylococcal scalded-skin syndrome

Stevens-Johnson syndrome

Toxic epidermal necrolysis

Toxic shock syndrome

von Zumbusch pustular psoriasis

Lymphadenopathy

Cervical

Kawasaki syndrome

Rubella

Scarlet fever

Generalized

Infectious mononucleosis

Secondary syphilis

Serum sickness

Sarcoidosis

Systemic lupus erythematosus

Toxoplasmosis

Hilar

Atypical measles

Sarcoidosis

Local

Cat-scratch disease

Tularemia

Meningitis

Acute meningococcemia

Cryptococcosis

Enterovirus (Coxsackieviruses, echoviruses)

Leptospirosis

Lyme disease

Rocky Mountain spotted fever

Secondary syphilis

Mucosal membrane lesions (enanthems)

Herpes simplex

Infectious mononucleosis (palatal petechiae)

Measles (Koplick's spots)= Strawberry tongue,Atypical measles,Kawasaki disease,Scarlet fever,Toxic shock syndrome

Varicella zoster

Ulcerative or vesicular stomatitis

Hand-foot-mouth disease

Herpes simplex

Histoplasmosis

Inflammatory bowel disease

Secondary syphilis

Systemic lupus erythematosus

Palm-sole involvement

Acute meningococcemia

Atypical measles

Dengue

Drug rash

Erythema multiforme

Hand-foot-mouth disease

Kawasaki syndrome

Measles

Rocky Mountain spotted fever

Secondary syphilis

Staphylococcus aureus endocarditis

Rash predominantly on extremities

Allergic purpura

Brucellosis

Disseminated gonococcal infection

Ecthyma gangrenosum

Erythema nodosum

Sporotrichosis (fever rare)

Pulmonary infiltrate

Atypical measles

Coccidioidomycosis

Cryptococcosis

Fat embolism

Histoplasmosis

Mycoplasma pneumoniae

North American blastomycosis

Psittacosis

Rocky Mountain spotted fever

Sarcoidosis

Varicella zoster

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of fever and rush according to ...., Inc. and/or its affiliatesin three categories:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete diagnostic aproach
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characteristics of the rash
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination
 
Laboratory testing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Macules
• Papules
• Nodules
• Plaques
 
 
 
 
 
• Vesicles
• Pustules
• Bullae
 
 
 
 
 
• Purpuric papules
• Purpuric macules
• Purpuric vesicles
 
 
 
 
 
Widespread erythema with or without edema followed by desquamation
 
 
 
• Vital signs
• General appearance
• Strict attention to lymph nodes, mucous membranes, genitalia and conjuctiva
• Evaluate liver and spleen size
• Joint examination
• Skin examination
 
Non-specific testing
 
• Complete blood count
• Urianalysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-infectious
 
Infectious
 
Non-infectious
 
Infectious
 
Non-infectious
 
Infectious
 
Non-infectious
 
Infectious
 
 
 
 
 
Blood culture
 
• Bacteria
• Mycobacteria
• Fungal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Serology test
 
• Coccidioides immitis
• Hepatitis B
• Toxoplasma Gondii
• Borrelia Burgdorferi
• Treponema Pallidum
• Dengue virus
• HIV
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bacterial
 
Viral
 
Fungal
 
 
 
 
 
 
 
 
Bacterial
 
Viral
 
Bacterial
 
Viral
 
 
 
Antigen test
 
Criptococcal antigen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bacterial
 
Viral
 
Fungal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fluorescent antibody or PCR or viral culture
 
• Varicella zoster
• herpes virus
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Darkfield microscopy or fluorescent antibody
 
Syphilis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunofluorescent
 
Rikettsia (Rocky mountain spotted fever)
 
 

1.Characteristics of the rash:

Macules, papules, nodules, or plaques

Noninfectious

Erythema multiforme

Systemic lupus erythematosus

Dermatomyositis

Drug hypersensitivities

Gianotti-Crosti syndrome

Inflammatory bowel disease

Pityriasis rosea (fever rare)

Sarcoidosis

Serum sickness

Sweet syndrome (acute febrile neutrophilic dermatosis)

Still's disease (juvenile idiopathic arthritis)

Bacterial

Arcanobacterium haemolyticum

Bacillus anthracis

Bartonella bacilliformis

Bartonella henselae (cat scratch disease)

Bartonella quintana (trench fever)

Borrelia burgdorferi (Lyme disease)

Borrelia spp (relapsing fever)

Brucella spp (brucellosis)

Calymmatobacterium granulomatis (donovanosis)

Chlamydia psittaci (psittacosis)

Ehrlichiosis

Ehrlichia chafeensis (HME)

Human granulocytic erlichiosis

Erysipelothrix rhusiopathiae (erysipeloid)

Francisella tularensis (tularemia)

Listeria monocytogenes

Leptospira spp (leptospirosis)

Mycobacterium leprae

Mycobacterium marinum

Mycobacterium tuberculosis

Mycoplasma pneumoniae

Neisseria gonorrhoeae (gonorrhea)

Neisseria meningitidis (meningococcemia)

Pseudomonas aeruginosa

Rickettsia akari (rickettsialpox)

Rickettsia prowazekii (epidemic/louse-borne typhus)

Rickettsia rickettsii (RMSF-early lesions)

Rickettsia orientalis/tsutsugamushi (scrub typhus)

Rickettsia typhi (endemic/murine typhus)

Salmonella typhi (typhoid fever)

Spirillum minor (rat-bite fever)

Fungal

Blastomyces dermatitidis

Candida spp

Coccidioides immitis

Cryptococcus neoformans

Histoplasma capsulatum

Other disseminated deep fungal infections in immunocompromised patients

Viral

Adenovirus

Arbovirus

Atypical measles

Chikungunya virus

Colorado tick fever

Coxsackieviruses A and B

Cytomegalovirus, primary infection

Dengue virus

Epstein-Barr virus, primary infection

Echoviruses

Hepatitis B (urticaria)

Human herpesvirus 6 (exanthem subitum)

Human immunodeficiency virus (HIV-1)

Kawasaki syndrome (presumed viral)

Molluscum contagiosum

Orf

Parvovirus B19 (erythema infectiosum [fifth disease])

Rubella (German measles)

Rubeola (measles)

Varicella (chickenpox)

Varicella-zoster (disseminated)

Viral hemorrhagic fevers (many)

West Nile virus

Zika virus

Vesicles, bullae, or pustules

Noninfectious

Erythema multiforme bullosum

Toxic epidermal necrolysis

Dermatitis from plants

Drug hypersensitivities

Bacterial

Bacillus anthracis

Ehrlichia canis

Listeria monocytogenes

Mycoplasma pneumoniae

Neisseria gonorrhoeae

Neisseria meningitidis

Pseudomonas aeruginosa

Rickettsia akari

Rickettsia rickettsii

Staphylococcus aureus (TSS, SSSS)

Streptococcus group A

Treponema pallidum (secondary syphilis)

Vibrio vulnificus

Fungal

Histoplasma capsulatum

Viral

Colorado tick fever

Coxsackie A5, 9, 10, 16, B2, 7

Echoviruses

Eczema herpeticum

Herpes simplex (disseminated)

Varicella (chickenpox)

Varicella-zoster (disseminated)

Purpuric macules, purpuric papules, or purpuric vesicles

Noninfectious

"Allergic" vasculitis

Erythroderma

Cholesterol embolization

Disseminated intravascular coagulation (purpura fulminans)

Drug hypersensitivities

Fat embolism

Henoch-Schönlein purpura

Immune thrombocytopenic purpura

Granulomatosis with polyangiitis (Wegener's)

Bacterial

Bacteremia

Borrelia spp

Clostridium spp

Infective endocarditis (many species)

Haemophilus influenzae type B

Neisseria gonorrhoeae (disseminated gonococcal infection)

Neisseria meningitidis (acute or chronic meningococcemia)

Pseudomonas aeruginosa

Rickettsia prowazekii

Rickettsia rickettsii

Spirillum minor

Staphylococcus aureus (bacteremia)

Streptobacillus moniliformis

Streptococcus group A (streptococcal toxic shock syndrome, scarlet fever)

Streptococcus pneumoniae (asplenic patient)

Vibrio vulnificus

Yersinia pestis

Viral

Adenovirus (rare)

Atypical measles

Chikungunya virus

Colorado tick fever

Congenital cytomegalovirus

Coxsackie A and B (rare, types A-9, B2-5)

Dengue fever

Epstein-Barr virus (rare)

Echoviruses (rare, types 3, 4, 9)

Rubella

Varicella-zoster virus

West Nile virus

Yellow fever

Widespread erythema with or without edema followed by desquamation

Noninfectious

Erythroderma

Drug hypersensitivities

Graft-versus-host reaction

Stevens-Johnson syndrome

Toxic epidermal necrolysis

von Zumbusch pustular psoriasis

Bacterial

Streptococcus group A (scarlet fever, streptococcal toxic shock syndrome)

Stapylococcus aureus (TSS, SSSS)

Viral

Kawasaki syndrome (presumed viral)


2.Physical examination

  • General appearance to assess the severity of illness

3.Laboratory testing


Treatment

Shown below is an algorithm summarizing the treatment of fever and rush disease according the the [...] guidelines.

Treatment of fever depending on the cause of the symptoms, in severe cases, a child might sometimes need to stay in the hospital.
patient of fever can take acetaminophen and ibuprofen, if patient have itchy viral rash, you can try applying a cool compress or calamine lotion to the affected area.


 
 
 
 
 
 
Child with fever and rush
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Infectious
 
 
 
 
 
 
 
Infectious
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat every case according to the cause of disease
 
 
 
Bacterial
 
Viral
 
Fungal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antibiotic and antihistaminic
 
• Rest
• Antipiretics
• Plenty of oral fluids
 
Antifungals according to the microorganism
 
 


Antibiotics can get rid of the infection, but they will not treat the rash, so we use the antibiotic in:


Do's[62]

  • Cough etiquette, contact precautions, and hand hygiene are easy and cost-effective measures in reducing the spread of infectious agents causing fever and rash.
  • For measles, mumps, rubella (MMR) prevention can be achieved by vaccination (two doses in childhood). In adolescents and adults, if none confirmatory immunization documentation exists, they need to receive two doses of MMR, at least 4-week apart.(Vaccines have been accepted in most national immunization programs)
  • Prevention of varicella and meningococcemia can also be achieved by vaccination. (vaccines have been accepted in most national immunization programs).
  • For meningococcal disease, chemoprophylaxis can also be useful. Among household contacts, the incidence of transmission of meningococcus is approximately 5%; therefore, it is recommended that household contacts of bacteriologically confirmed cases receive rifampin (adults: 600 mg bid for a total of 4 doses; children older than 1 month: 10 mg/kg; children younger than 1 month: 5 mg/kg). These contacts should be advised to watch for fever, rash, sore throat, or any symptoms of meningitis. Intimate, non-household contacts who have had mucosal exposure to the patient’s oral secretions should also receive prophylaxis. Health-care workers are not at an increased risk for the disease and do not require prophylaxis unless they have had direct mucosal contact with patient secretions (i.e., mouth-to-mouth resuscitation, endotracheal intubation, or nasotracheal suctioning). Ciprofloxacin (500 mg by mouth; adults only) or ceftriaxone (250 mg IM for adults or 125 mg IM for children) are single dose alternatives.
  • With the increasing vector borne diseases (e.g., Zika, chinkungunya, dengue, yellow fever) efforts to prevent mosquito bites are cornerstone. Some of the recommended measures in persons living or traveling to endemic areas are:
  • Long-sleeved shirts and pants.
  • If possible, keep indoors at sunset.
  • Cover water storage containers so that mosquitos cannot get inside to lay eggs.
  • Discard or empty regularly any items that hold water like tires, buckets, pools, birdbaths, flowerpot saucers, or trash containers.
  • Sleep under a mosquito bed net if you are overseas or outside and are not able to protect yourself from mosquito bites.
  • Use Environmental Protection Agency (EPA)-registered insect repellents with one of the following active ingredients: DEET (≥20%), picardin, IR3535, oil of lemon eucalyptus, or para-menthane-diol. For men who live in or have traveled to an area with Zika, and have a pregnant partner they either have to use condoms correctly from start to finish, every time they have vaginal, anal, and oral sex, or do not have sex during pregnancy. Women who had Zika virus disease should wait at least 8 weeks after exposure to attempt conception and men with Zika virus disease should wait at least 6 months after symptom onset to attempt conception. Women and men with possible exposure to Zika virus but without clinical illness consistent with Zika virus disease should wait at least 8 weeks after exposure to attempt conception.

Don'ts

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