Approach to a child with fever and rash

complete guide to a child with rash.
algorithm of diagnosis.
includes infectious diseases.
final year mbbs pediatric presentation

1. AN APPROACH TO A CHILD WITH FEVER AND SKIN RASH Dr ANAKHA P

2. INTRODUCTION This condition can be caused by drug reaction, infection or an allergic reaction. Different agents can cause rash that look the same Often symptoms in addition to rash helps in making the diagnosis. Most rashes caused by viruses do not harm child but some are life threatening.

3. 10% of all febrile children have dermatological problem. Morphology of skin lesion can contribute to diagnosis. In drug reactions we see more than one type of morphology at a given point of time. At times lesion goes through stages, in such cases presenting lesion along with relevant evidence from history on evolution helps in diagnosis.

4. AETIOLOGY Allergy: Urticaria Drug rash Allergic vasculitis Infection: Measles Rubella Varicella Dengue Scarlet fever Typhoid meningococcemia

5. Other illnesses: Kawasaki disease SLE Erythema multiforme Toxic epidermal necrolysis(TEN) Staphylococcal scalded skin syndrome(SSSS) Erythema marginatum Erythema infectiosum Dermatomyositis Hand foot and mouth disease (HFMD)

6. DIAGNOSIS CAN BE MADE BY: History taking Cinical examination. Relevant laboratory work up

7. HISTORY WITH REGARD TO FEVER : Onset Duration Diurnal variation. Other symptoms. WITH REGARD TO RASH: Distribution of rash Morphology or pattern of rash. Evolution Prodrome , if any

8. CLINICAL EXAMINATION Grade of fever. Pattern of fever. Type of skin lesion. Distribution Site of first appearance. Evolution Tenderness Mucosal involvement Involvement of palms, soles.hair.nails . Other systems.

9. MORPHOLOGY OF LESIONS MACULE: Circumscribed area of change in skin color without any change in consistency. <1cm diameter PAPULES AND NODULES: Solid lesion <0.5cm in diameter; major part of it projecting above the skin is a papule. Solid lesion >0.5cm but <1cm in diameter with major part in the skin is a nodule .

10. PLAQUE: Area of altered skin consistency, surface area of which is greater than depth. WHEAL: Characteristic lesion in urticaria . Pale or erythematous raised lesion which disappears within 24-48hrs. BLISTERS: Circumscribed elevated, superficial fluid filled cavity. If <0.5cm it is a vesicle; >0.5cm a bulla

11. PETECHIAE : pin head sized macules of blood. PURPURA: large petechiae which do not blanch on pressure. ECCHYMOSIS: large extravasation of blood in the skin.

12. CAUSES OF MACULAR OR MACULOPAPULAR RASH COMMON: Measles Rubella Dengue Roseola infantum Erythema infectiosum Drug rash Adenoviral or enteroviral infections.

13. Less common: IMN Chikungunya HIV Typhus CMV

14. MEASLES Eruptive (rash) phase: Rash appears on 4-6 day of fever. MORPHOLOGY- Faint erythematous maculopapular rash. DISTRIBUTION- Starts behind the ears, involving the face & spreading to trunk& then to legs and arms. By the time it appears on feet ,it starts disappearing from face in the same order. Temperature normalises once rash starts fading. Severity is proportionate extent & confluence of rash.

15. RUBELLA PRODROME: low grade fever Malaise sorethroat Post auricular, sub-occipital lymph nodes :enlarged & tender. Rose spots on soft palate ( forchheimer spots)before rash. RASH MORPHOLOGY Discrete maculopapular rash variable in size and confluence. DISTRIBUTION Starts on face & spreads rapidly over trunk. Progression is fast. By 3 rd day rash clears up without significant desquamation.

16. MEASLES (RUBEOLA) GERMAN MEASLES (RUBELLA) Coryza &cough more severe. Coryza & cough mild Confluent maculopapular rash with slow progression and clearing. Discrete maculopapular rash with rapid progression and clearing. Temperature rises abruptly with rash . Temperature don’t rise abruptly with rash. Lymphadenopathy not characteristic Retro-auricular, post . Cervical or post.occipital lymphadenopathy is characteristic. Kopliks spots may be seen Forschheimers spots may be seen.

17. DENGUE Rashes are seen in febrile phase and during convalscence . FEBRILE PHASE: During fever, whole body invariably covered with bloachable erythematous flush. Suffused & swollen face, injected eyes, reddened ears,crimson malar area,swollen & purplish lips(measly look). Flush deepens with advancing disease. In few patients, maculopapular exanthem erupt on top of erythematous flush.

18. Hemorrhagic manifestations include petechiae and mucous membrane bleed. Early febrile phase shows positive torniquet test. RECOVERY PHASE: (CONVALSCENCE) Termination of illness is swift, marked by a distinctive acral exanthem . Bright red confluent petechial rash along lateral margins of soles and palms. In some areas there are small round areas of clear skin giving it a name of annular petechial rash.(white isles in sea of red).

19. HESS CAPILLARY RESISTANCE TEST IT IS ALSO KNOWN AS TOURNIQUET TEST. Part of new WHO case definition of dengue. Marker of capillary fragility. Steps: Take patients BP. Inflate the cuff to a point midway between SBP & DBP and maintain for 5min. Reduce and wait 2min. Count petechiae below antecubital fossa. A POSITIVE TEST IS 20 PETECHIAE PER 1 SQUARE INCH.

20. DENGUE POSITIVE TOURNIQUET TEST

21. ROSEOLA INFANTUM(sixth disease) – Herpes virus 6,7 rash with defervescence . ERYTHEMA INFECTIOSUM(fifth disease) : Parvovirus p19 Slap cheek appearance. Maculopapular rash on extensor aspect. IMN: Rash appears after giving ampicillin (20% children) CHIKUNGUNYA: Rashes are seen on the trunks & limbs; also on face,palms & soles. Petechiae occur alone or in association with rash.

22. ROSEOLA ERYTHEMA INFECTIOSUM IMN CHIKUNGUNYA

23. CAUSES OF VESICULAR RASH COMMON: Chicken pox Hand foot mouth disease. LESS COMMON: Herpes simplex Herpes zoster Papulo necrotic tuberculosis.

24. CHICKEN POX : Moderate fever -- 2-3 days; maculopapular rash MORPHOLOGY: After appears which later turns into vesicles filled with clear fluid which becomes cloudy & umblicated (dew drops on rose petals) Intensely pruritic . DISTRIBUTION: predominant on flexor surfaces. Palms& soles are seldom affected. Pleomorphic .

25. HERPES ZOSTER: Uncommon in children. Reactivation of latent VZV. MORPHOLOGY: clustered vesicular rash on erythematous base. DISTRIBUTION: 1 OR 2 dermatomes.

26. HAND FOOT MOUTH DISEASE . Caused by viruses of genus enterovirus. Rash is seen on palms and soles; less commonly on flexors.

27. CAUSES OF PETECHIAL OR PURPURIC RASH COMMON: Meningococcemia Henoch schonlein purpura. DHF. LESS COMMON: Hemorrhagic measles. Gonococcemia Cutaneous vasculitis . Indian spotted fever.

28. HSP : Common vasculitic disorder of childhood. Non-thrombocytopenic palpable purpura. Rash over the extensor aspects of lower extremities and buttocks. MENINGOCOCCEMIA: Rashes starts as scattering of small pin prick marks.(reddish or brown). Later large patches of purple or red blotches or blood blisters. Will not blanch with pressure.

29. HSP MENINGOCOCCEMIA

30. CAUSES OF ERYTHEMATOUS RASH COMMON: Kawasaki disease. TEN(Toxic epidermal necrolysis) SJS LESS COMMON: TScarlet fever. SS.

31. NIKOLSKYS SIGN This sign is present when slight rubbing of the skin results in exfoliation of the skin in its outermost layer. Formation of new blisters in slght pressure (Direct Nikolsky ) Shearing of skin due to rubbing (Indirect Nikolsky )

32. TOXIC EPIDERMAL NECROLYSIS: Immune complex mediated. Skin lesions begin as hot,tender,erythematous,morbilliform or descrete macules that rapidly coalesce & become patches of loose skin.

33. KAWASAKI DISEASE: Necrotizing vasculitis of medium sized muscular arteries (coronaries). fever atleast 5days. Edema , erythema of hands & feet. Periungual desquamation. Polymorphous rash (never vesicular). Strawberry tongue.

34. CAUSES OF URTICARIAL RASH COMMON: Scabies Insect bites. LESS COMMON: Cutaneous larva migrans due to hookworm,strongyloids,pediculosis .

35. CAUSES OF NODULAR RASH COMMON: Erythema nodosum due to TB Drugs ( penicillin,sulphonamides , anticonvulsants, anti TB , gentamicin ). Molluscum contagiosum Lepromatous leprosy. LESS COMMON: Disseminated histoplasmosis cryptococcosis .

36. DAY SPECIFIC RASH 1 st DAY – Varicella. 2 nd DAY- Scarlet fever. 3 rd DAY- Small pox 4 th DAY- Measles. 5 th DAY – Typhoid 6 th DAY-Dengue 7 th DAY- Typhus.

37. LABORATORY WORK-UP Complete haemogram Urine microbiology Blood biochemistry. Smear examination from skin lesion. Gram/ leishman /AFB staining. Dark field microscopy. LE cell test. Blood serology Skin biopsy.

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