Fever and rash in children Dr. A. Gervaix, 2005

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
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FEVER & RASH ?