Fever with Rash in Pediatrics PDF

# Fever with Rash ## What is fever? Fever means a temperature above 100.4°F (38°C). It is a normal response to a variety of conditions, the most common of which is infection. ## What is rash? A rash is a change of the human skin which affects its color, appearance, or texture. A rash may be loca...

# Fever with Rash ## What is fever? Fever means a temperature above 100.4°F (38°C). It is a normal response to a variety of conditions, the most common of which is infection. ## What is rash? A rash is a change of the human skin which affects its color, appearance, or texture. A rash may be localized in one part of the body, or affect all the skin. ## Presentation * **Features of the rash:** * Characteristic of lesions * Distribution and progression * Timing of onset in relation to fever * Morphological changes (e.g., papules to vesicles) ## Common Skin Lesions * **Macule:** non palpable, circumscribed, flat lesion (<1 cm in diameter). * **Papule:** palpable, elevated lesion (<1 cm in diameter). * **Maculopapular:** combination of macular and popular lesions. * **Purpura:** non-blanching papules or macules. * **Vesicle:** fluid-filled, elevated skin lesion (<1 cm in diameter). * **Bulla:** fluid-filled, elevated skin lesion (>1 cm in diameter). * **Pustule:** pus-containing vesicle. * **Cyst** * **Fissure** * **Nodule** * **Polyp** * **Wheal** ## History It is important to consider the following: * Age of patient * Season * Travel history * Geographic location * Exposures to insects, animals, other people who are ill * Medications * Immunization history ## Physical Examination * **Distribution Pattern:** * Symmetrical eruption * Asymmetrical rashes * **Morphology:** * Monomorphic * Pleomorphic * **Configuration:** * Linear, annular, grouped, * Koebner phenomenon (eruption in an area of local trauma) ## Differential Diagnosis of Fever with Rash | LESION | DESCRIPTION | PATHOGENS OR INFECTION | |---|---|---| | a) Maculopapular rash | -macules-red/pink discrete flat areas, blanch on pressure -papules-solid, raised hemispherical lesions, tiny, blanch on pressure | VRS - Measles, rubella, roseola, erythema infectiosum, EBV, echovirus, HBV, HIV BACT - Erythema marginatum, scarlet fever, erysipelas, 2° syphilis, leptospirosis, Lyme dzs, RICK - Rocky Mountain Spotted fever, Typhus OTH - RA, Kawasaki dis, drug rxn | | b) Diffuse erythroderma | - thickened, scaly skin on palms and soles | BACT - Scarlet fever, Toxic Shock Syndrome, Staph SSS FUNGI - Candida albicans OTH - Kawasaki syndrome | | c) Urticarial rash | -swelling of the lesions -appear n resolve rapidly | VRS - EBV, Hep B, HIV BACT - M.pneumonia, Grp A strep. OTH - Drug rxn | | d) Vesicular, pustular, bullous | -Vesicular - raised hemispherical lesions, <0.5cm, contain clear fluid -Pustular, bullous- raised hemispherical lesion, >0.5cm, contain clear/purulent fluid | VRS - HSV, VZV, Coxsackievirus BACT - Staph.SSS, Staph. Bullous impetigo, Strep. crusted impetigo OTH- Toxic epidermal necrolysis, Steven-Johnson Syndrome. RICK - Rickettsial pox | | e) Petechial-purpuric | - non-blanching red/purple spots | VRS - Atypical measles, congenital rubella, CMV, enterovirus, HIV, HF viruses BACT - Sepsis (meningococcal, gonococcal, pneumococcal, Hib), IE | | f) Erythema Nodosum | - tender red nodules, due to exudation of blood and serum | RICK - Rocky mountain spotted fvr FUNGI - Aspergillus, mucor OTH - Vasculitis, thrombocytopenia, Henoch-Schönlein purpura, malaria VRS - EBV, HBV BACT - Group A Streptococcus TB, yersinia, Cat-Scratch Dzs FUNGI - Coccidiomycosis, histoplasmosis OTH - Sarcoidosis, Inf. Bowel dzs, OCP, SLE, Behçet dzs | ## Differential Diagnosis: Infectious Causes ### 1. Measles: * Blanching erythematous maculopapular rash. * Begins in head and neck and spreads centrifugally to trunk and extremities. * Associated symptoms: fever, cough, coryza and conjunctivitis. * Diagnosis: Measles IgM is detectable for 1 mon after illness. * Treatment: Supportive. ### 2. Chickenpox * Initially as small red papules that rapidly progress to oval, non umbilicated, "teardrop" vesicles on erythematous base. * Lesions are present in different stages: papules, vesicles, crusting. * New crops appear for 3 to 4 days, beginning on the trunk followed by the head, the face, and, less commonly, the extremities. * PCR is the current diagnostic method of choice. * Treatment: Supportive. ### 3. Rubella * Rash resembles measles, but patient is not ill looking. * Prominent posta uricular, posterior cervical +/- suboccipital adenopathy. * Forschemier spots: small, red spots (petechiae) on soft palate in 20% of rubella patients. * Ig M antibodies diagnostic for congenital rubella syndrome. * Treatment: Supportive. ### 4. Scarlet Fever * Exotoxin-mediated diffuse erythematous rash. * Pharyngitis due to group A streptococcus. * Coarse, sandpaper-like, erythematous, blanching rash à desquamation. * Circumoral pallor and strawberry tongue. * Diagnosis: group A Streptococcus is present in throat swab. * Treatment: rehydration, antibiotics (Amoxicillin 40 mg per kg per day). ### 5. Dengue Fever * Dengue fever is a tropical, mosquito-borne(by female Aedes aegypti) disease that causes flu-like symptoms, rashes and joint and muscle pain. * High fever of 106°F (41°C). * Skin rash, which appears three to four days after the onset of fever. * Eye and joint aches. * Backaches and headaches. * Loss of appetite. * Nausea and Vomiting. * Bleeding nose and gums. * Diagnosis: by isolation of the virus, by serological tests. * Treatment: supportive. ### 6. Typhoid Fever * Is a bacterial infection caused by salmonella. Which is common in countries with poor sanitation. * Persistent fever that rises gradually to 39°C to 40°C (102°F to 104°F). * Temporary rash 2 to 4 mm in diameter with raised pink blanching spots on the stomach or chest. * Headache and sore throat. * Tiredness and low energy. * Stomach pain, Constipation, and diarrhea. * Diagnosis: blood and stool culture. * Treatment: rehydration and cephalosporin. ### 7. Typhus * Is a disease caused by infection of rickettsial bacteria and is transmitted by invertebrate animals known as arthropods. Presents with: * Severe headache * High fever (above 102.2°F). * Rash that begins on the back or chest and spreads. * Confusion and Stupor. * Hypotension. * Eye sensitivity to bright lights. * Severe muscle pain. * Diagnosis: skin biopsy of rash, Western blot and immunofluorescence test. * Treatment: Doxycycline. ## Inflammatory Causes: Kawasaki Vasculitis * Usually in kids <4 years old. * Fever >5 days. * Bilateral conjunctival injection, injected or fissured lips. * Injected pharynx or "strawberry tongue". * Erythema of palms or soles. * Edema of hands or feet. * Generalized or periungual desquamation. * Rash. * Cervical lymphadenopath. * Acute rheumatic fever. * Treatment: intravenous immunoglobulin (IVIG) and Aspirin. ## Systemic Lupus Erythromatosis * An autoimmune disease in which the body's immune system mistakenly attacks healthy tissue in many parts of the body. * Pleuritis or pericarditis. * Discoid rash which affects the skin, causing a red, scaly rash with raised borders on areas of the body that are exposed to sunlight. * Malar rash and photosensitive rash. * Oral (Ulcers). * Arthritis. * Anemia, leukopenia, lymphopenia orthrombocytopenia. * Renal Nephritis. * Diagnosis: ANA, Immunoreactive (anti-Ds DNA, Anti-Rho, Anti-Sm, Anti-La, antiphospholipid). ## Infectious Mononucleosis * Caused by Epstein-Barr virus (EBV). * Has particular tropism for B lymphocytes and epithelial cells of the pharynx. * Transmission usually occurs by oral contact. ## Presentation of Infectious Mononucleosis * Fever. * Malaise. * Tonsillopharygitis - often severe, limiting oral ingestion of fluids and food, rarely breathing can be compromised. * Lymphadenopathy - prominent cervical lymph nodes. * Petechiae on the soft palate. * Splenomegaly (50%), hepatomegaly (10%). * Maculopapular rash (5%). ## Treatment of Infectious Mononucleosis ### Medical Care Closely monitor patients with extreme tonsillar enlargement for airway obstruction. Steroids are indicated for impending or established airway obstruction in individuals with Epstein-Barr virus (EBV) infectious mononucleosis. ### Surgical Care Surgery is necessary for spontaneous splenic rupture, which occurs in rare patients with EBV infectious mononucleosis and may be the initial manifestation of the condition. # Acute Gastroenteritis (AGE) Gastroenteritis is defined as the inflammation of the mucus membranes of the Gastrointestinal tract and is characterized by diarrhea, fever, and vomiting. ## Definitions and Terms * **Diarrhea:** the frequent passage of liquid stools (3 or more loose, watery stool per day) * **Dysentery:** blood or mucus in stools # Causes of Deaths Among Children Under 5 Years The pie chart shows that diaarhea accounts for 1.34 million deaths annually in children younger than 5 years. # Causes of Acute Gastroenteritis in Children * **Viruses (~70%)** * Rotaviruses * Norwalk (noroviruses) * Adenoviruses * Caliciviruses * Astroviruses * Enteroviruses * **Protozoa** * Giardia lamblia * Entamoeba histolytica * Cryptosporidium * **Bacteria (~15%)** * Enterotoxigenic Ecoli * Campylobacter jejuni * Salmonella spp * Enteropathogenic E. coli * Shigella spp * Yersinia enterocolitica * Cholera * C difficile * **Helminths** * Strongyloides stercoralis # Viral Infections | Virus | Character | Incubation period | Duration | |---|---|---|---| | Rota virus | Commonest dehydrating diarrhea | 1-3 d | 5-7 d | | Norwalk virus (noroviruses) | Outbreaks of GE in both children and adults | 1-3 d | 1-2 d | | Adeno virus | 2ND common after rota | 8-10 d | 5-12 d | # Bacterial Infections * E. coli infection, typhoid, and shigellosis are more common in developing communities. * **Clostridium difficile : ** pseudomembranous colitis, observed in patients who develop severe diarrhea during or following a course of antibiotics. * In patients with sickle cell disease, Salmonella species are the most frequent cause of gastroenteritis # Protozoal Agents * Cryptosporidium species * G lamblia * Entamoeba histolytica # Sign & Symptoms of Acute Gastroenteritis * Nausea & Vomiting * Diarrhea * Loss of appetite * Fever * Headaches * Abdominal pain * Bloody stools * Fainting and Weakness * Heartburn * Dehydration * Lethargic # Diarrhea * ***Watery*** stools are more consistent with viral gastroenteritis. * Stools with ***blood*** or ***mucous*** are indicative of a bacterial pathogen. * **A long duration of diarrhea (>14 days)** * Parasitic * Noninfectious cause of diarrhea. # Differential Diagnoses of Diarrhea 1. Infections outside the gastrointestinal tract (eg, AOM, URI) 2. Chronic nonspecific diarrhea of childhood (toddler diarrhea) 3. Malabsorption syndromes 4. Inflammatory Bowel Disease 5. Pediatric Lactose Intolerance # Lab Studies * **Are not required** if the etiology is apparent and some dehydration is present. **With severe dehydration,** the following are suggested * **Serum electrolytes:** Because hyponatremia and hypernatremia require specific treatment. * **Bicarbonate concentration:** Useful in ruling out dehydration. Poor tissue perfusion in dehydration results in production of lactic acid. Loss of bicarbonate in diarrheal stools. * **Glucose:** May be dangerously low because of poor intake. * **Blood urea and creatinine:** Elevated in renal hypoperfusion. * **Urine specific gravity** * **Stool examination / culture** # Stool Examination * Presence of pus, RBC, or gross blood. * No pus or RBC * Stool cultures or rectal swab. * Virus detection # Evidence of Systemic Infection - Complete Workup (for Stool Examination): CBC and blood cultures. If indicated, urine cultures, chest radiography, and/or LP. # Complications of Acute Gastroenteritis 1. **Dehydration:** Acidosis, shock and death. 2. Electrolyte imbalance. 3. Seizures. 4. Secondary carbohydrate malabsorption. 5. Hemolytic uremic syndrome. # Symptoms of Dehydration * Irritability * No tears when crying. * Sunken eye. * Thirst. * Lethargy. * Dry mouth and skin. # Skin Turgor Skin turgor is assessed by pinching the skin of the abdomen or thigh between the thumb and the bent forefinger in a longitudinal manner. The sign is unreliable in obese or severely malnourished children. # Severe Dehydration * Abnormally sleepy * Lethargic * Sunken eyes ## Clinical Findings of Dehydration: | Symptom | Minimal or no Dehydration (<3%) | Mild to Moderate (3%-9%) | Severe (>10%) | |---|---|---|---| | Mental Status | Alert | Normal, restless, irritable | Lethargic, unconscious | | Thirst | Normal PO or refuses | Thirsty | Drinks poorly or unable | | Heart Rate | Normal | Normal to increased | Tachycardia | | Quality of pulses | Normal | Normal to decreased | Weak or impalpable | | Breathing | Normal | Normal to fast | Deep | | Eyes | Normal | Slightly sunken | Deeply sunken | | Tears | Present | Decreased | Absent | | Oral mucosa | Moist | Dry | Parched | | Skin fold | Instant recoil | Recoil in < 2 sec | Recoil > 2sec | | Capillary refill | Normal | Prolonged | Prolonged; minimal | | Extremities. | Warm | Cool | Cool, mottled, cyanotic | | Urine output | Normal to decrease | Decreased | Minimal | # Seizures in a Patient with Diarrhea * **Causes:** * Shigella species * Enterohemorrhagic Escherichia coli * Electrolyte imbalance, Na # Management of Acute Gastroenteritis ## Basic Guidlines for the Management of Dehydration: * **ORS** should be used for rehydration. * Oral rehydration should be performed within 3–4 hr. * **Rapid realimentation** (an age-appropriate unrestricted diet is recommended as soon as dehydration is corrected. Gut “rest” is not indicated). ## Management of Dehydration by Breastfeeding or Formula: * In breastfed infants, nursing should continue. * Diluted formula or special formulas are not indicated. * Additional ORS can be administered for ongoing losses. * No unnecessary labs or medications (i.e. antidiarrheals.) ## Minimal or no Dehydration * **If the child is breastfed,** give breastfeeding more frequently than usual and for longer at each feed. * **If not breastfed,** then ***oral fluids*** (including clean water, soup, rice water, yogurt drink) * **For ongoing fluid losses** give 10 mL/kg ORS for each loose stool and 2 mL/kg for each episode of emesis. ## Composition of Oral Rehydration Solutions: | Solution | Carbs (gm/L) | Sodium (mmol/L) | Potassium (mmol/L) | Chloride (mmol/L) | Base (mmol/L) | Osmolarity (mOsm/L) | |---|---|---|---|---|---|---| | WHO-ORS (2002) | 13.5 | 75 | 30 | 65 | 30 | 245 | | WHO-ORS (1975) | 20 | 90 | 20 | 80 | 30 | 311 | | Pedialyte | 25 | 45 | 20 | 35 | 30 | 250 | | Enfalyte | 30 | 50 | 25 | 45 | 34 | 200 | | Rehydralyte | 25 | 75 | 20 | 65 | 30 | 305 | | CeraLyte | 40 | 50-90 | 20 | N/A | 30 | 220 | | Gatorade | 14 | 110 | 30 | N/A | 30 | 290-303 | | Apple Juice | 120 | 0.4 | 44 | 45 | N/A | 730 | | Coca-Cola | 112 | 1.6 | N/A | N/A | 13.4 | 650 | **In the human body, the plasma osmolality is about 285 mOsm/l.** ## Mild-to-moderate Dehydration * Give 50-100 mL/kg of ORS over a 2- to 4-hour period. * After the initial rehydration phase, manage as before. * ORS should be given slowly at a rate of 5 mL every 1-2 min. * **For patients who do not tolerate ORS by mouth**, nasogastric (NG) feeding. ## Hypernatremic Dehydration * **An exception to this, is the management of hypernatrernic dehydration (>150 mmol/L of sodium).** Hypernatremic dehydration should be corrected with the same volumes of ORS described above, but over 12 hours instead of 4 hours. * This reduces the risk of seizures associated with rapid correction of hypernatremia in mild-to-moderate dehydration. ## Rapid Correction of Hypernatremic Dehydration * **Brain edema** ## When to Admit Children with AGE 1. Inability to tolerate oral rehydration therapy. 2. Severely dehydrated or in shock. 3. **At high risk of dehydration** * < 6 months old * High frequency of watery stools or vomits. * Minimal oral intake. * Worsening symptoms. * If the parent or carer is unable to manage the child at home. 4. **At high risk of complications** * Children with significant underlying disease (eg, diabetes, renal failure, SCD..) * High fever. * Poor nutrition. * Hypernatremic. * Hyponatremic states. ## Severe Dehydration * Is a medical emergency. * **IV bolus of 20-30 mL/kg (LR)** or (NS) solution over 60 minutes. * Repeat till pulse, perfusion, and/or mental status improve. * **After this, the patient should be given an infusion of 70 mL/kg LR or NS over 5 hours (children < 12 months) or 2.5 hours (older children).** * **Once resuscitation is complete**, rehydration should continue with ORS as described above. ## Children with Severe Dehydration Children with severe dehydration should be admitted for IV fluids. # Antimicrobials (for Acute Gastroenteritis) * **Generally not indicated** * **C difficile:** stop antibiotic & start metronidazole. * **Cholera:** tetracycline and doxycycline. * **Giardia:** metronidazole. * **Cryptosporidium:** metronidazole or Nitazoxanide. # Antidiarrheals * **Antidiarrheals are not recommended** * Loperamide has been linked to cases of severe abdominal distention and even death. * **Ondasetron** * A serotonin antagonist antiemetic. * Effective in decreasing vomiting and facilitates ORT. * Proven efficacious and safe in children ≥ 6 months. * Shown to shorten the ED stay. # Probiotics * Probiotics are live microbial feeding supplements. * Possible mechanisms of action include synthesis of antimicrobial substances, competition with pathogens for nutrients, modification of toxins, and stimulation of nonspecific immune responses to pathogens. * **Two large systematic reviews have found probiotics (especially Lactobacillus GG) to be effective in reducing the duration of diarrhea.** * A recent meta-analysis found probiotics may be especially effective for the prevention of C difficile -associated diarrhea in patients receiving antibiotics. # Zinc * Zinc supplementation may be effective in reducing the duration of diarrhea in children older than 6 months in areas where zinc deficiency is prevalent. * **WHO recommends zinc supplementation (10-20 mg/day for 10-14 days) for all children younger than 5 years with acute gastroenteritis.** * Little data support this recommendation for children in developed countries. # Prevention of Diarrhea * **Vaccination-RotaTeq & Rotarix** * **Probiotics** * Washing hands. * Clean food preparation & preservation. * **References**