Pediatric presentation

Rash with fever in children

Is the child well or unwell, does the rash blanch, and where did it start: the morphology is DermSpace's, the sick child is ours.

What are you worried about?
- Meningococcal disease: a non-blanching rash with fever
- Kawasaki disease
- Toxic shock syndrome, staphylococcal scalded skin syndrome
- Measles in the unimmunized
- Drug reactions with mucosal involvement (Stevens-Johnson syndrome)
Differential, by age
Infant 1 to 12 months
Roseola (fever first, rash as the fever breaks)
Viral exanthems
Meningococcemia
Kawasaki disease (under 1 year is atypical and higher risk)
Toddler 1 to 3 years
Viral exanthems
Hand-foot-and-mouth disease
Scarlet fever
Kawasaki disease
Meningococcemia
Preschool 3 to 5 years
Scarlet fever
Fifth disease (slapped cheek)
Varicella if unimmunized
Kawasaki disease
IgA vasculitis
School age 6 to 11 years
Scarlet fever
Fifth disease
IgA vasculitis
Drug reaction
Mycoplasma-associated rash
Adolescent 12 to 17 years
Infectious mononucleosis (rash after amoxicillin)
Drug reaction
Meningococcemia
Disseminated gonococcal infection
Systemic lupus
Key history
- Which came first, the fever or the rash; where the rash started and how it spread
- Mucous membranes: red eyes, red lips, a strawberry tongue; mouth ulcers
- Medications in the last two weeks; immunizations; sick contacts; travel
- Joint pain, abdominal pain, swelling of hands and feet, peeling
- How the child is behaving between fevers
Key examination
- Undress fully: blanching test with a glass, distribution, mucosa, palms and soles, the nappy area
- Appearance and perfusion before anything else
- Conjunctivae, lips, tongue, lymph nodes (Kawasaki criteria)
- Neck stiffness, fontanelle, joints
- Nikolsky sign where the skin is tender
Red flags
- Non-blanching petechiae or purpura with fever, especially with ill appearance
- Fever of 5 or more days with red eyes, red lips, rash, extremity changes or lymphadenopathy
- Mucosal involvement, skin pain, blistering
- Shock, altered mental status
- A rash in an unimmunized child with coryza, conjunctivitis and cough (measles)
Initial investigations
- A well child with a typical viral exanthem needs none
- Ill or non-blanching: blood cultures, full count, coagulation, C-reactive protein, lactate, then antibiotics within the hour; do not wait for a lumbar puncture
- Suspected Kawasaki: inflammatory markers, platelets, liver enzymes, urinalysis, and an echocardiogram
- Throat swab for scarlet fever; isolation and public health for measles
How to interpret them
- Petechiae only above the nipple line in a well child who has been coughing or vomiting are usually mechanical; below it, or with fever, they are meningococcus until proven otherwise
- Kawasaki is a clinical diagnosis: the criteria are prompts, and incomplete Kawasaki exists
- Thrombocytosis is a second-week feature of Kawasaki, not a first-week one
When the child is deteriorating
- Suspected meningococcal disease: antibiotics immediately, fluid resuscitation, senior help, intensive care early
- Kawasaki: intravenous immunoglobulin within the first 10 days protects the coronary arteries
Cases and practice
No longitudinal case yet for this presentation; the conditions below and the practice drills cover it.
Practice drills Acute pediatrics