Fever and rash in children Dr. A. Gervaix, 2005 Fever and rash in children Diffential diagnosis of fever and rash Viruses Maculo/papular rash Vesicular, bullous Petechial Diffuse erythroderma Bacteria Measles, rubella, HHV-6 GABHS (scarlet fever)… EBV, HBV, HIV, enterovirus.. Salmonella, Lyme, Mycoplasma pneumoniae VZV, HSV, Echovirus Impetigo (GAS) … Coxsackievirus A, B CMV, enterovirus, EBV Hemorrhagic fever, VZV Dengue Urticarial rash EBV, HBV, HIV, Enterovirus… Other Rickettsia Sepsis (N.men, S.pneu,Hib) Rickettsia Rat bite fever (S. minus)… GABHS (scarlet fever), TSS M. pneumoniae, GAS C. albicans Fever and rash in children Essential elements of the history in the clinical assessment of fever and rash • Demographic data Age Gender Ethnicity Season Geographic area •Exposures Ill contacts (home, day care…) Travel Pets, insects Medications and drugs Immunization • Associated symptoms Focal (suggesting organ-specific illness) Systemic (multisystem illness) • Features of rash Temporal association (onset relative to fever) Progression and evolution Location and distribution Pain or pruritus • Prior health status Medical and surgical history Growth and development Recurrent infectious illnesses •Family history Fever and rash in children Essential elements of the physical examination in the clinical assessment of fever and rash • Degree of toxicity • Characteristics of rash Macular Papular Maculo-papular Petechiae or purpura Diffuse/localized erythroderma Vesicles, pustules, bullae Nodules • Associated enanthem Buccal and genital mucosa Palate Pharynx and tonsils • Associated findings Arthritis, ocular, GI, cardiac… Fever and rash in children History: Clinical case #1 9 mo old girl, good general health condition Progressive fever for 3 days (max. 39.50C) Coryza, exudative conjontivitis, severe cough and irritability No diarrhea, no vomiting No recent travel, no pets Attends day care 2d/w Confluent maculo-papular rash all over the body Fever and rash in children Measles Acute viral infection Human being is the only reservoir Caused by a paramyxovirus Very contagious (reach 90% of susceptible contacts within a family. Respiratory route) Fever and rash in children Measles Clinical features Incubation period: 10-12 days Prodroms: 3-5 days coryza, conjunctivitis, cough, fever Koplick’s spots Rash Fever and rash in children Measles Koplik’s spots Pathognomonic of measles Fever and rash in children Measles Fever and rash in children Measles • The rash starts behind the ears and on the forehead at the hair line • The spread of the rash is centrifugal (head to legs) Fever and rash in children Diagnosis: Clinical Serology Viral culture PCR Measles Fever and rash in children Complications (more severe in adults) • Acute otitis media (10-15%) • Interstitial pneumonia (50-75% pathological chest RX) • Myocarditis and pericarditis • Encephalitis (1/1000 cases) 7-10 days after rash (1/3 died, 1/3 sequeallae, 1/3 full recovery) • Subacute sclerosis panencephalitis (SSPE) (0.2-2 /100’000 infections, mean incubation 7 y.) Case fatality rate is 100% after 6 to 9 months Measles Fever and rash in children Measles Treatment • No specific antiviral treatment • Vaccination within 72h after contact • Immunoglobulins within 6 days after contact in immunocompromised and < 1 y old children Fever and rash in children Measles is a preventable disease !!! Live attenuated vaccine (combined with rubella and mumps): 2 doses Reported cases of measles in Maryland, Fever and rash in children Important notice … Eradication of measles can be obtained if >95% of the population is immune Measles is endemic if 15-20% of the population is susceptible Epidemics can occur if > 25% of the population is susceptible … vaccinate your children « No evidence for measles, mumps, and rubella vaccine-associated inflammatory bowel disease or autism in a 14-y prospective study » Peltola et al. Lancet 1998 without fear Fever and rash in children Clinical case #2 History: 7 y. old boy, good general health condition Sudden onset of sore throat since 24h and fever at 390C. Abdominal pain and 1 episode of vomiting No conjuntivitis, No rhinitis, No hoarseness No cough Attends primary school, no recent travel Maculo-papular rash Fever and rash in children Scarlet fever - Scarlatina Scarlatina is caused by erythrogenic exotoxin producing strains of Group A ß-hemolytic Streptococci Common among school-age children (very unsual in < 2 y old) 5-10% of healthy carriers Transmission by direct contact or respiratory droplets Incubation: 2 to 5 days Untreated cases remain infectious for a prolonged period, unlikely after 24h of appropriate antibiotic therapy Fever and rash in children Clinical features Abrupt onset Fever Sore throat Abdominal pain Variable pharyngitis Tender lymphadenopathy Fever and rash in children Scarlet fever - Scarlatina Diffuse erythroderma (red sandpaper) • The rash develops often within 12h (always within 2d) after the onset of symptoms • Generalized confluent rash on the cheeks and forehead but with circumoral palor • Spreads onto the neck and trunk, sparser on the limbs • Usually involves palms and soles of feet Fever and rash in children Scarlet fever - Scarlatina Thick, white layer through which red papillae protrude (white strawberry tongue) Peeling after several days (red strawberry tongue) Pintpoint petechiae in the flexures produce a linear purpuric pattern (pathognomonic) = Pastia’s lines Fever and rash in children Scarlet fever - Scarlatina After a week, the rash typically starts to desquamate, particularly on the hands and feet Fever and rash in children Scarlet fever - Scarlatina Complications of GAS infection Local: Otitis media Pharyngeal abcess Adenitis Invasive: Sepsis Non suppurative: Glomerulonephritis rheumatic fever erythema nodosum (No more likely to follow scarlet fever than other group A streptococcal infection) Fever and rash in children Scarlet fever - Scarlatina Diagnosis: Clinical Rapid strep test Culture ASLO Treatment: Antibiotics (penicillin) Fever and rash in children Clinical case #3 History: 6 y. old girl, good general health condition headache, abdominal discomfort. Temp. 38.30C Goes to school after 3 days bright erythematous facial exanthem Fever and rash in children « Slapped cheek disease », fifth disease, erythema infectiosum Caused by Parvovirus B19 Discovered in 1975 Causes spring epidemics in children 4-10y (attack rate 40%) Often asymptomatic Seroprevalence of 50% at age 15 Seroconversion of 1.5%/y in childbearing aged women Fever and rash in children Incubation of 4-14 days Stage I Mild prodromal illness low grade fever headache GI symptoms Stage II (+3-7 days) Erythematous facial exanthem (slapped cheeks ) Stage III (+1-4 days) Lacy maculo-papular exanthem on the trunk and extremities. May be pruritic, evanescent, recurring over 1-3 weeks Arthropathy (adults >> children, female >> male) Erythema infectiosum Clinical features Fever and rash in children Erythema infectiosum Children are infectious during the prodromal stage and do not shed virus at the time of the rash anymore Control of epidemics very difficult Fever and rash in children Complications of parvovirus B19 infection • Erythrocyte aplasia (by direct infection of the red cell precursors) • Intrauterine infection (hydrops fetalis (5% of infected fœtus), rash, hepatomegaly, cardiomegaly and anemia) Fever and rash in children Parvovirus B19 Diagnosis Clinical Serology (arthritis, red cell aplasia..) Treatment No specific treatment Fever and rash in children Clinical case #4 History: 6 month old boy, No past medical history No prodromes Fever 400C of sudden onset Febrile convulsion 3 days later the fever abates and widespread macular rash Fever and rash in children Caused by Human herpes virus type 6 (HHV-6B) in rare cases by HHV-7 • Discovered in 1988 • >95 % of children are affected • Almost all cases between 4 mo and 2 years • Sporadic illness (rare outbreaks) • No seasonal distribution • Reactivation possible (immunosuppressed persons) Roseola infantum, exanthem subitum, « sixth disease » Fever and rash in children Clinical manifestations • Often asymptomatic • Few prodromes (rhinorrhea, diarrhea) • Sudden onset of fever (39-400C) lasting 3-5 days • Rose-coloured macular rash, rarely confluent, present for few hours up to 2days Affects the neck and trunk extending to the face and proximal extremities • No pruritus, no desquamation Associated with febrile convulsion ROSEOLA Fever and rash in children ROSEOLA Diagnosis • Clinical • Serology • PCR Treatment • Symptomatic (antipyretics) Fever and rash in children Clinical case #5 History: 5 y old boy, no special past medical history Low grade fever (38.30C) for 48 h Attends school No travel history No pets Vesicular rash on the trunk and face Fever and rash in children Caused by varicella/zoster virus (VZV, herpes virus family) Most common exanthematous disease of childhood Humans are the only reservoir Affects 90% of children between 1 to 14 years Highly contagious (>90% in household contacts) Contagiosity: 2 days before to 5 days after the rash Varicella /chickenpox Fever and rash in children Varicella /chickenpox Occurs in late winter early spring Less common in tropical climates Incubation period 14 days (10-21) Replication at the site of infection, primary viremia which establishes replication in the reticulo-endothelial system. A secondary viremia occurs after about a week with disseminates to the skin Establishment of latency in sensory ganglia reactivates years later to cause zoster Fever and rash in children Varicella /chickenpox Clinical manifestations Prodromes with 1-2 days of low grade fever • • • • Erythematous papules Vesicules Pustules Crust Spread from the trunk to the face, neck and extremities Pruritus +++ Mucous membranes can be involved The hall mark of the varicella rash is the simultaneous presence of lesions of different stages Fever and rash in children Diagnosis • Clinical • Serology • Immunofluorescence • Culture • PCR Varicella /chickenpox Fever and rash in children Varicella /chickenpox Complications • Congénital infection (2%, 18-22 w of gestation) Small size, cutaneous scarring, limb hyplasia, microcephaly, cortical atrophy, chorioretinitis, cataracts …. • Perinatal infection 5 days before to 2 days after birth (high mortality without treatment 30%) Fever and rash in children Varicella /chickenpox Complications #2 Increase with age •Pneumonia Rare in children, high mortality in immunocompromised host) • Cerebellar ataxia (1/4000 in <15 y) Develops 7 to 10 days into the disease, excellent prognosis • Transvere myelitis, Guillain-Barre sy. • Hemorrhagic varicella Thrombocytopenia Fever and rash in children Varicella /chickenpox Complications #3 • Superinfections locally with S. aureus or GABHS cellulitis systemic with GABHS sepsis, necrotizing fasceitis Strep. TSS • Reye syndrome Persistant vomiting, decreasing mental status, liver failure. Associated with salicylate-containing products Avoid aspirin in varicella !!! Fever and rash in children Treatment Varicella /chickenpox Fever and rash in children Varicella /chickenpox Secondary prevention Must be administered by 96h after exposure (or better if < 72h) Primary and secondary prevention by a vaccine Fever and rash in children Clinical case #6 History: 20 mo old boy High fever (39.50C) for 5 days remittent with several spikes each day Irritable No cough Physical examination Bad general condition Polymorphous rash conjunctival injection fissured lips cervical lymphadenopathy (>1.5 cm) No travel history No pets Vaccination: OK for the age Fever and rash in children KAWASAKI disease First described in 1967 Incidence: 67 cases /100’000 in Japan 5.6 cases/100’000 in the USA 85% in children < 5 years (peak 18-24 mo) Rarely occurs in adolescent, adults or children < 6 mo . M/F ratio 1.4:1 Occurs often in late winter and spring Etiology: UKNOWN Pathophysiology: « Superantigen theory » causing an intense vasculitis Fever and rash in children KAWASAKI disease Clinical presentation 92% 65% Fever and rash in children KAWASAKI disease Clinical presentation 75% Fever and rash in children KAWASAKI disease Clinical presentation 77% 90% 50-75% Fever and rash in children KAWASAKI disease Associated findings Aseptic meningitis (25%) Arthritis and arthralgia (20-40%) Diarrhoea Hydrops of the gallbladder Laboratory High ESR and CRP Sterile pyuria High platelet count (second week) Differential diagnosis Measles, scarlet fever TSS, Steven-Johnson sy, Juvenile rheumatoid arthritis… Fever and rash in children Complications KAWASAKI disease Coronary aneuvrysm Prognosis 75% no sequelae, 25% coronary abnormality (without treatment), 1-2% mortality in the acute phase Fever and rash in children KAWASAKI disease Treatment Immunoglobulins 2g/kg body weight Aspirin 80-100 mg/kg/day during the acute phase then 3-5 mg/kg/day for months when fever subsides Have you questions about FEVER & RASH ?
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