Fever and Rash

Macule: discolored spot (often, but not necessarily red; often, but not necessarily round); blanches
Papule: raised spot
Maculopapular: a papule rising from a macule, often red
Petechia: pinpoint purple/red bruise; does NOT blanch, often in clusters
Ecchymosis: red/purple bruise, variable size & shape
Definitions

Case #1
3-year-old male with:
fever x several days
total body rash (red maculopapular) began 2 days after fever
cough, runny nose, & red eyes
irritability

Maculopapular rash

Measles
“Stepwise” high fever
Cough, coryza, and conjunctivitis
Rash (exanthem) starts on head & spreads to rest of body
Koplick spots (enanthem) prior to or at very beginning of rash
Complications: OM, diarrhea, encephalitis, pneumonia

Koplick Spots

Measles (Rubeola)
Highly contagious
Most deadly of all childhood rash/fever illnesses
Spread by droplets or direct contact with nasal or throat secretions of infected persons
Incubation period: 8 -12 days
Prevention: immunization (MMR) just past one year & before kindergarden

Case #2
13-year-old male with:
fever x two days
generalized rash
On PE:
Well & comfortable
Maculopapular rash
Postauricular lymphadenopathy

Rubella (German Measles)
Low grade fever
Rash:
starts on face & spreads down body, clearing in same pattern
Light red spots, fainter than measles
Lasts 1 - 3 days
Mild illness, may be missed
Adults & adolescents may have arthritis or arthralgia
Complications: encephalitis, neuritis & in pregnancy ? Congenital Rubella Syndrome in baby

Congenital Rubella
Rash
Cataracts
CHD (PDA)
Blindness
Neurosensory deafness
Microcephaly & mental retardation

Rubella
Droplet transmission
Incubation period: 2 - 3 weeks
Prevention: Vaccination (MMR)

Case #3
15-month-old presents with several days of fever, & rash that looks like this:

Fifth Disease,
Erythema Infectiosum
Parvovirus B19
Fever, malaise & headache may precede rash by up to 10 days
“Slapped cheeks” and “lacy, reticular” rash over body that may itch
No longer infectious once rash develops
Virus may also cause polyarthropathy syndrome, aplastic crisis, or hydrops fetalis

Hydrops Fetalis

Case #4
8-month-old female with fever to 40°C for past 5 days
Baby does not look unwell
PE reveals no source of fever
U/A negative
WBC mildly elevated; mostly lymphocytes
D/C on acetaminophen
Next day mother calls to say baby has a rash

Roseola (Sixth disease, Exanthem subitum)
Peak incidence 6-24 months
20% of HHV-6 infections
Also HHV-7
Self-limited disease:
3-7 days of fever
Rash follows defervescence
Febrile seizures in 10-15%
Occasionally, bulging fontanelle & encephalopathy

Case #5
3-year-old boy with fever & irritability x 6 days.
PE:
maculopapular rash
red eyes
strawberry tongue
cervical lymphadenopathy

Scarlet Fever
Group A β Strep
Generalized rash:
Sandpapery
Circumoral pallor
Pastia’s lines

Pastia’s lines
Circumoral pallor

Kawasaki Syndrome
Mucocutaneous Lymph Node Syndrome
3 phases:
Acute: 1-2 wks, fever, etc
Subacute: ≈ 2-4 wks
After acute signs ?
Convalescent: ≈ 6-8 wks
about 4th wk; when clinical signs disappear
Until ESR returns to normal

Kawasaki Syndrome
Mucocutaneous Lymph Node Syndrome
Acute Phase:
Fever for at least 5 days (usually 1-2 wks, may last 3-4 wks) plus 4/5 of following criteria:
Rash (maculopapular, erythema multiforme or scarlatiniform; ? in groin area)
Lymphadenopathy (non suppurative, ≥1.5cm, usually unilateral)
Bulbar conjunctival injection
Mucosal changes (mouth & pharynx redness; perineal dequamation)
Extremity changes (hands & feet erythema & swelling)

Kawasaki Syndrome:
Subacute phase
Irritability, anorexia & conjunctival injection may persist
Periungual desquamation of fingers & toes
Thrombocytosis
Coronary aneurysms (greater risk with prolonged fever)
Greater risk of sudden death

Kawasaki Syndrome:
Associated findings:
? acute phase reactants (APRs)
Thrombocytosis
Sterile pyuria
Elevated LFTs
Hydrops of gallbladder
Aseptic meningitis

Kawasaki Syndrome:
Coronary aneurysm
20 - 25% of patients not treated within 10 days
High risk: male, Asian, < 1 year, >8 years, anemia, persistent fever after treatment
1- 4 weeks after onset of illness, uncommon after 6 weeks
Case fatality rate < 0.01%, primarily from myocardial infarction

Kawasaki Syndrome:
Treatment
Intravenous Immune Globulin 2g/kg x1
Aspirin:
80-100 mg/kg/day until fever ? x 14 day, then
3-5mg/kg/day x ≥ 6-8 weeks
Warfarin for hi risk patients
Follow echocardiograms
Need to re-treat in 5-10%

Case #6
A 10-year-old male presents in September, with fever & rash
Questions?
Tick-borne diseases in NY?
Lyme disease in
US: southern New England & eastern Middle Atlantic states, less on Pacific coast
Europe: Scandinavia, Germany, Austria, Switzerland
20-100 cases/100,000 pop’n in endemic areas

Erythema chronicum migrans

Lyme Disease
Borrelia burgdorferi transmitted by:
Ixodes tick
Ehrlichia, babesia

Lyme Disease: early localized
Erythema migrans:
About 1-2 weeks after tick bite, at site of bite; usually axilla, periumbilical, groin & thigh
May be itchy or painful
May be associated with fever, myalgia, h/a or malaise
Without treatment, expands to ≈ 15cm x ≥ 1-2 wks

Lyme Disease:
early disseminated
20% develop smaller secondary lesions due to hematogenous spread; continue to appear x several wks
Fever, myalgia, h/a or malaise
Conjunctivitis
Lymphadenopathy
Aseptic meningitis
+++

Lyme Disease:
late disseminated
Arthritis after wks to mos
Large joints, especially knees (90%)
Swollen, tender, but not too pianful
Usually resolves within 1-2 wks

Lyme Disease
Screen with EIA (enzyme immunoassay), always confirm with Western blot
Treat with oral doxycycline/amoxicillin
x 14 days
Prevention:
wear protective clothing
Check for & remove tics after exposure

Case #7
14-year-old male presents with one week history of fever & throat pain
Seen by PMD yesterday & prescribed amoxicillin for presumed streptococcal pharyngitis (throat culture pending)
Referred for evaluation of possible amoxicillin allergy

Epstein Barr Virus
Most common cause of mononucleosis syndrome:
Transmitted in oral secretions by close contact, eg, kissing
Shed in oral secretions up to 6 mos post infection
Incubation period 30- 50 days in adolescents
Silent infections in infants & young children

Infectious Mononucleosis
Fever, fatigue, exudative pharyngitis, petechiae on palate, abdominal pain
Hepatosplenomegaly, enlarged lymph nodes, atypical lymphocytosis
Diagnose with EBV-specific serology or atypical lymphocytes >10% & + Monospot
Supportive therapy, no contact sports until spleen ok

Case #8
4-year-old child with fever, sore throat & rash x 3 days
PE significant for red, painful, sandpaper-y rash over body; perioral pallor & strawberry tongue

Scarlet Fever
Group A Streptococcus (S. pyogenes)
Erythrogenic toxin
Accentuation of rash in creases = Pastia’s lines
-Rash desquamates after ~1 week
Treat with penicillin to avoid suppurative /non-suppurative sequelae

Case #9
18-month-old girl presents with fever & rash for last 12 hours
On initial PE, she is febrile & cranky, but otherwise appears stable
While awaiting results of CBC in ER, rash progresses, & she becomes progressively obtunded

Neisseria meningococcemia
Can present insidiously or in fulminant fashion
High risk: asplenic, terminal complement deficiency (C5-C9), properdin deficiency
Complications: purpura fulminans, Waterhouse Friedrichsen syndrome (hemorrhage into adrenals ? adrenal shock), DIC, death
Treat with penicillin & supportive therapy
Prophylax household or daycare contacts in 7 days prior to onset of disease

Case #10
2-year-old male with rash to face & fever for three days. Rash worsening since onset.
Has had this rash before.

HSV Stomatitis
Can affect any age groups
Toddlers: drooling = spread of lesions, can also see whitlow
Immunosuppressed at high risk
Usually HSV-1
Diagnose clinically, or by DFA/cx if diagnosis uncertain
Treatment: supportive +/acyclovir

HSV Stomatitis

Whitlow

Case #11
3-year-old child presents in July with fever for 3 days, & refusal to eat or drink

Hand-Foot-and-Mouth Disease
Coxsackie A16 & Enterovirus 71
Oral lesions only: herpangina
Vesicles on an erythematous base, at posterior pharynx/soft palate
Commonly presents in spring & summer
Supportive care

Case #12
2-year-old child presents with fever for four days & rash for two days.
His father, who is visiting from Mexico to harvest strawberries, brought him to a walk-in clinic.