Fever and rash in children

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Fever and rash in children Microchapters

Overview

Classification

Pathophysiology

Causes

Epidemiology and Demographics

Risk Factors

Natural History, Complications, and Prognosis

Diagnosis

Treatment

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:

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

b. Varicella/Chickenpox

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

b. Blastomycosis

c. Coccidiodomycosis

d. Histoplasmosis

e. Lyme disease

f. Relapsing fever

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

Common causes of fever and rash in kids may include:

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 Neisseria 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-Schonlein Purpura

Juvenile Rheumatoid Arthritis

Juvenile Dermatomyositis

Drug-related eruptions Erythema multiforme

SJS

TEN

Epidemiology and Demographics

Age

  • Patients of all age groups may develop diseases that present with fever and rash.

Race

  • There is no racial predilection to diseases that present with fever and rash.

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:

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

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.

Symptoms

Besides fever and rash, additional symptoms of diseases includes the following:

Important details to watch out for in the history include:

Physical Examination

In addition to symptoms already listed above, additional findings on examination include;

Laboratory Findings

Laboratory tests for the various diseases is largely dependent on etiology. They are needed mostly to support diagnosis. Some lab findings needed to support diagnosis of some diseases are as follows:

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

A practical approach to triage kids who present with fever and rash for near accurate diagnosis and treatment is to divide them into 3 groups on basis of initial presenting symptoms:

a. 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.

b. 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.

c. 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.

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 washingfrequently 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. 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.
  2. https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-1
  3. https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-2
  4. https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-3
  5. https://www.consultant360.com/articles/rashes-and-fever-children-sorting-out-potentially-dangerous-part-4
  6. 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. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.