Fever with rash-Parents guide

Dr Hesham last
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Dr.Hesham Farouk

Specialist Pediatrician

Aster Discovery gardens &Arabian Ranches

Fever accompanied by rash is a common finding in pediatric patients. Although, in most cases, the disease is trivial, in some cases it may be the
first and/or the sole manifestation of a serious and life- threatening condition in patients.

The spectrum of differential diagnosis is broad and many different infectious and some noninfectious agents cause this syndrome.

To establish a timely diagnosis, providing appropriate therapy and considering proper preventive measures if necessary, a systematic
approach relying on a clear history, careful clinical examination along with particular attention to epidemiological features are the most
important factors to pursue this syndrome.




A fever is not a disease but a sign that the body’s immune system is fighting an infection. The body raises its core temperature to fight off the invading bacteria or viruses.

Children aged 1–3 years old, generally referred to as toddlers, often get illnesses because:

their immune systems have not yet fully developed
they have increased exposure to germs from other children, especially in day care or preschool
they tend to put their hands or objects in their mouths
Fever usually goes away once the illness passes. However, toddlers sometimes develop a rash following a fever. Although this is rarely severe, it is important to see a doctor immediately.

Most common Causes and differential diagnosis :

 

 



  • Roseola infantum

Roseola infantum, which is also called roseola or sixth disease, is a viral infection. Babies and toddlers pass on the virus through saliva, coughing, and sneezing.

Roseola may cause a sudden, high fever of 102–105°F that lasts for 3–6 days. Some children are active and comfortable with no other symptoms during this stage of the illness, but others may also experience:

decreased appetite or unwillingness to eat
eye swelling or conjunctivitis, also known as pink eye
a cough
a runny nose
diarrhea
swollen lymph nodes
sleepiness or irritability
Typically, the symptoms of roseola go away suddenly on the sixth or seventh day of illness. After these symptoms have cleared up, the rash appears.

baby with roseola rash

 




In most cases, the roseola rash:

consists of small pink spots, about 2–5 millimeters (mm) wide
may be slightly raised or flat
starts on the trunk and may spread to the arms, neck, and face
does not itch or hurt
disappears when pressed, which is known as blanching
fades after 1–2 days

The incubation period for roseola is 7–14 days, which means that symptoms may not appear until 1–2 weeks after becoming infected. Antibiotics do not work against roseola, but extra fluids and fever-reducing medicine can relieve symptoms.

Parents and caregivers should keep children with roseola out of school or day care until they have been free of fever for 24 hours without the use of medication. The rash from roseola is not contagious.




Up to 15 percent of children with roseola may also experience a febrile seizure, which can happen as a result of the high fever and the ability of the virus to cross into the brain.

During a febrile seizure, the child may:

lose consciousness
start shaking their arms and legs uncontrollably
become stiff
roll their eyes
wet or soil themselves
vomit
froth at the mouth
Febrile seizures generally only last a few minutes. According to the National Institute of Neurological Disorders and Stroke, there is no evidence that short febrile seizures cause brain damage. Most children will recover without any problems.





However, the parent or caregiver should immediately call an ambulance if:

it is the child’s first febrile seizure
the seizure lasts longer than 5 minutes
the child has a stiff neck, is vomiting excessively, or is extremely lethargic
During the seizure, it is vital to:

remain calm and time the length of the seizure
carefully place the child in a safe location to protect them from accidental injury
position the child on their side or front to prevent choking
carefully remove any objects from the child’s mouth

 

  • Erythema Infectiosum (Slapped Cheek Syndrome/Fifth Disease)

 

Presentation:
 Non-specific viral symptoms
 Rash appears few days later, firm red cheeks, burning hot, perioral sparing
 Lace like pink rash follows on limbs and occasionally trunk

fifth disease childs cheeks

Investigations:
 Clinical diagnosis
 Can be confirmed with blood tests:
o Parvovirus serology; IgG, IgM (Lithium heparin bottle)
o Parvovirus PCR (EDTA)

Management:
 No specific treatment- reassurance and emollients
 No school exclusion required (infectious before rash evident)
 Ice cold flannel can relieve discomfort/burning of cheeks
Note:
 Infection in pregnant woman can cause spontaneous abortion, intrauterine death
and hydrops fetalis therefore must avoid contact and seek advice from midwife.
 Can cause a transient aplastic crisis in children with chronic haemolytic disorders e.g.
sickle cell and spherocytosis- observe haemoglobin.




  • Measles:

Presentation:
 Prodromal cold-like symptoms: miserable, fever, conjunctivitis, cough and corzya
 Koplik spots – small blue-white spots on inside of mouth, appear 24-48 hours before exanthema

kopliks spots




 Day 4-5: blotchy, non-itchy, red rash behind ears and spreads from face down
towards body. Appearance coincides with high fever
 Begins to fade after 3-4 days

    This is the skin of a patient after 3 days of measles infection.

High risk:

Under 2 months (infants who have lost passive immunity pre 1st set of
immunisations)
Immunocompromised individuals regardless of immunisation status
 Late teenage years- may not have been immunised
 High risk of increased severity:
 Malnourishment
 Immunodeficiency
 Pregnancy
Investigations:
 Suspected cases require confirmation:
 Viral nasopharyngeal swab & throat swab for PCR within 7d of onset of rash
 Bloods: IgM and IgG antibodies

Management:



Rubella is a much milder disease in children that’s also caused by a virus (rubivirus). Symptoms may begin 14-21 days after exposure to the virus. If contracted in the womb, rubella is a much more serious disease, causing deafness, heart abnormalities, eye problems, retardation, and other conditions in the newborn.

Symptoms in children
Rubella begins with a pink/red rash on the face then spreads to the rest of the body and gets better in about 4 days.
Your child does not appear to be very ill but may develop swollen lymph nodes in the neck, especially behind the ears.

 

Rash of rubella on skin of child's back. Distribution is similar to that of measles, but the lesions are less intensely red.

 



Investigations:
 Clinical diagnosis
Management:
 No specific treatment – usually mild and self limiting
 School exclusion rules apply whilst patient is infectious 7 days before and 7 days
after rash
 Notification to infection control and Public Health England
 Contact tracing – ask about contact with pregnant women
 Must be confirmed serology not clinically
Complications:
 Conjunctivitis
 Thyroiditis
 Arthritis
 Post-infectious encephalitis
 In pregnancy can cause stillbirth, miscarriage or congenital rubella syndrome

Prevention

  • Rubella is also easily prevented with an effective vaccine (the MMR).
  • Rubella can be very serious to an unborn child if the mother develops rubella early in her pregnancy. All women of childbearing age should have their immune status verified.

Supportive
 Analgesia and IV hydration if clinically indicated
 Admit severe or high risk individuals for careful observation to prevent complications
 Notification to infection control and Public Health England
Common Complications:
 Pneumonia- primary viral or secondary bacterial (most common cause of death =
1:5000 cases in UK)
 Diarrhoea – can be fatal
 Otitis media – may lead to deafness
 Convulsions
Rarer Complications:
 Encephalitis
 Sub-acute sclerosing pan-encephalitis
 Bronchitis
towards body. Appearance coincides with high fever
 Begins to fade after 3-4 days
 High risk:
 Under 2 months (infants who have lost passive immunity pre 1st set of
immunisations)

 

 Immunocompromised individuals regardless of immunisation status
 Late teenage years- may not have been immunised
 High risk of increased severity:
 Malnourishment
 Immunodeficiency
 Pregnancy
Investigations:
 Suspected cases require confirmation:
 Viral nasopharyngeal swab & throat swab for PCR within 7d of onset of rash
 Bloods: IgM and IgG antibodies
Management:
Supportive
 Analgesia and IV hydration if clinically indicated
 Admit severe or high risk individuals for careful observation to prevent complications
 Notification to infection control and Public Health England
Common Complications:
 Pneumonia- primary viral or secondary bacterial (most common cause of death =

 

1:5000 cases in UK)
 Diarrhoea – can be fatal
 Otitis media – may lead to deafness
 Convulsions
Rarer Complications:
 Encephalitis
 Sub-acute sclerosing pan-encephalitis
 Bronchitis
Rubella (German measles)

 



  • Scarlet fever (Scarlatina)

 

Scarlet fever results from an infection with group A Streptococcus bacteria. This type of bacteria can also cause strep throat and specific skin infections, such as impetigo.

Infected children can pass on the bacteria through:

coughing and sneezing
sharing food or drinks
letting other people touch a skin lesion, where there is a skin infection
Symptoms of scarlet fever may include:

a temperature of 101°F or higher
red rash that starts on the neck, underarms, or groin area and spreads across the body
red, sore throat
white coating or red bumps on the tongue
redness in skin creases, such as under the arms and inside the elbows and inner thighs
a headache
body aches
nausea, stomach ache, or vomiting
The rash from scarlet fever feels rough like sandpaper. It usually appears 1–2 days after the fever starts but can present up to 7 days later.

The area around the mouth usually remains pale, even if the rest of the face looks red. After the rash has faded, the skin may peel.

A child with symptoms of scarlet fever should see a doctor as soon as possible. In rare cases, group A strep infections can cause severe complications, such as heart or kidney problems.

Doctors treat scarlet fever with antibiotics. A child may return to school or day care once they have been taking antibiotics for at least 24 hours.

 

 

Treatment
Streptococcal bacteria can be treated with antibiotics.
Have your child seen by your doctor immediately if you suspect he or she has strep throat or scarlet fever.
Your child will require a full course of antibiotics, which should be completed even if your child is feeling better before he or she completes the course.
Your child may return to school 24 hours after starting the antibiotics if the fever has resolved and he or she is feeling better.

  • Kawasaki disease

Causes
No one knows what causes Kawasaki disease, but scientists don’t believe the disease is contagious from person to person. A number of theories link the disease to bacteria, viruses or other environmental factors, but none has been proved. Certain genes may make your child more likely to get Kawasaki disease.





Overview
Kawasaki disease causes swelling (inflammation) in the walls of medium-sized arteries throughout the body. It primarily affects children. The inflammation tends to affect the coronary arteries, which supply blood to the heart muscle.

Kawasaki disease is sometimes called mucocutaneous lymph node syndrome because it also affects glands that swell during an infection (lymph nodes), skin, and the mucous membranes inside the mouth, nose and throat.

Signs of Kawasaki disease, such as a high fever and peeling skin, can be frightening.

The good news is that Kawasaki disease is usually treatable, and most children recover from Kawasaki disease without serious problems.

 

Symptoms

Kawasaki disease signs and symptoms usually appear in three phases.

1st phase

Signs and symptoms of the first phase may include:

    • A fever that is often is higher than 102.2 F (39 C) and lasts more than three days
    • Extremely red eyes without a thick discharge
    • A rash on the main part of the body and in the genital area
    • Red, dry, cracked lips and an extremely red, swollen tongue
    • Swollen, red skin on the palms of the hands and the soles of the feet
    • Swollen lymph nodes in the neck and perhaps elsewhere
    • Irritability




2nd phase

In the second phase of the disease, your child may develop:

  • Peeling of the skin on the hands and feet, especially the tips of the fingers and toes, often in large sheets
  • Joint pain
  • Diarrhea
  • Vomiting
  • Abdominal pain

3rd phase

In the third phase of the disease, signs and symptoms slowly go away unless complications develop. It may be as long as eight weeks before energy levels seem normal again.

Picture of Kawasaki's Disease

 

  • Hand, foot, and mouth disease:

Hand, foot, and mouth disease (HFMD) is common in children under 5 years old. Several different viruses can cause this illness, and children can pass on the infection through:

saliva
coughing and sneezing
fluid from blisters
poop
HFMD often starts with a fever, but it may also cause a sore throat, lack of appetite, and malaise.




After about 1–2 days, sores and a rash may appear. The telltale signs of HFMD include:

sores in the back of the mouth that are small initially but turn into painful blisters
flat, red spots on the palms of the hands or the soles of the feet
flat, red spots or blisters on the buttocks or groin
Some toddlers might get all of these symptoms, while others may only get mildly sick without any other problems. A parent or caregiver should get advice from a doctor on when a child with scarlet fever should return to school or day care.




Although most cases of HFMD resolve on their own, the sores can be painful. If a child is unable to eat or drink, there is a risk of dehydration. Children who are not eating or drinking or who seem very ill should see a doctor.

   

 

The Tumbler test

it is for Checking if a Rash is NonBlanching
Do the ‘tumbler test’ if your child has a rash. Press a glass tumbler
firmly against the rash. If you can see the spots through the glass and
they do not fade at all this is called a ‘non-blanching rash’. If this type of
rash is present seek medical advice immediately.
If the spots fade/lighten when the glass is rolled over them, the rash is
probably not serious, but keep checking, it can develop occasionally
into a rash that does not fade.
Rashes are harder to see on dark skin so look for rashes on paler
areas, such as palms of the hands, soles of the feet and on the tummy.

 

  • Differential diagnosis

Table 1 from Differential Diagnosis of Viral Exanthemas | Semantic Scholar