Evaluating the Febrile Patient with a rash D. TAREK SAYED pediatric departement MCH Buraydah

The differential diagnosis for febrile patients with a rash is extensive. 

causes

viruses bacteria Spirochetes rickettsiae Medications rheumatologic diseases Allergic

infectious

Non infectios

Rashes can be categorized as:- maculopapular -petechial- diffusely erythematous with desquamation -vesicular-bullous-pustular -nodular

Because the severity of these illnesses can vary from minor (roseola) to life-

threatening (meningococcemia), the physician must make prompt management decisions regarding imperical theraby. 

Evaluating the patient who presents with fever and a rash can be challenging because the differential diagnosis is extensive and includes minor and life-threatening illnesses

Ringworm Worms don't cause

ringworm. It's caused by a fungus that lives off dead skin, hair, and nail tissue. It starts as a red, scaly patch or bump. Then comes the telltale itchy red ring. The ring has raised, blistery, or scaly borders. Ringworm is passed on by skin-to-skin contact with a person or animal. Kids can also get it by sharing things like towels or sports gear. You may treat it with antifungal creams.

Fifth Disease This contagious and usually

mild illness passes in a couple of weeks. Fifth disease starts with flu-like symptoms. A bright face and body rash follow. It’s spread by coughing and sneezing and most contagious the week before the rash appears. It's treated with rest, fluids, and pain relievers (do not give aspirin to children). If your child has fifth disease and you are pregnant, call your doctor.

Chickenpox This once-common rash isn't

seen as much in today's kids thanks to the chickenpox vaccine. It’s very contagious, spreads easily, and leaves an itchy rash and red spots or blisters all over the body. The spots go through stages. They blister, burst, dry, and crust over. Chickenpox can be very serious. All young kids should get a chickenpox vaccine. So should teens and adults who never had it or the shot.

Impetigo Impetigo, caused by bacteria,

creates red sores or blisters. These can break open, ooze, and develop a yellow-brown crust. Sores can show up all over the body but mostly around the mouth and nose. Impetigo can be spread through close contact or by sharing things like towels and toys. Scratching can spread it to other parts of the body. It's treated with antibiotic ointment or pills.

Warts A virus causes these funky

but mostly harmless, painless skin growths. Warts can spread easily from person to person. They also spread by touching an object used by a person with the virus. They're most often found on fingers and hands. To prevent warts from spreading, tell your child not to pick them or bite nails. Cover warts with bandages. Most warts go away on their own.

Contact Dermatitis Some kids' skin reacts after

touching foods, soaps, or plants like poison ivy, sumac, or oak. The rash usually starts within 48 hours after skin contact. Minor cases may cause mild redness or a rash of small red bumps. In severe cases you may see swelling, redness, and larger blisters. This rash goes away after a week or two or when contact ends.

Hand-Foot-Mouth Disease (Coxsackie)

Despite its scary name, this is a common childhood illness. It starts with a fever, followed by painful mouth sores and a non-itchy rash. The rash blisters on hands, feet, and sometimes buttocks and legs. It spreads through coughing, sneezing, and used diapers. So wash hands often. Coxsackie isn’t serious and usually goes away on its own in about a week.

Eczema Kids prone to eczema may

have other allergies and asthma. The exact cause isn't clear. But kids who get it tend to have a sensitive immune system. Watch for a raised rash with dry skin and intense itching. Atopic dermatitis is the most common type of eczema. Some children outgrow it or have milder cases as they get older.

Hives Many things can trigger these

itchy or burning welts. Medicines such as aspirin (which kids should never take) and penicillin can set off hives. Food triggers include eggs, nuts, shellfish, and food additives. Heat or cold and strep throat can also cause hives. Welts can show up anywhere on the body and last minutes or days. Sometimes an antihistamine can help. Hives can be a sign of serious problems, especially when they come with breathing troubles or swelling in the face. In those cases or if hives don't go away, see your doctor.

Scarlet Fever Scarlet fever is strep throat

with a rash. Symptoms include sore throat, fever, headache, belly pain, and swollen neck glands. After 1-2 days, a red rash with a sandpaper texture shows up. After 7-14 days, the rash rubs off.  Scarlet fever is very contagious, so wash hands often to keep it from spreading. Call your child's doctor if you think your child has it. He'll probably  be treated with with antibiotics.

Roseola (Sixth Disease) Roseola, a mild illness, gets

its nickname from a list of six common childhood rashes. Young kids 6 months to 2 years are most likely to get it. It's rare after age 4. It starts with a cold, followed by a few days of high fever (which can trigger seizures). Then the fevers end suddenly. They're followed by a rash of small, pink, flat, or slightly raised bumps. It shows up first on the chest and back, then hands and feet.

Rubella (German Measles) Rubella, also called German

measles, is a mild virus that usually causes no serious problems. However, it can harm the fetus if a pregnant woman becomes infected. The symptoms are a low fever and rash that spreads from the face to the rest of the body. A standard childhood vaccine called MMR protects against measles, mumps, and rubella.

Lyme Disease The hallmark of Lyme disease

is a target-shaped rash that appears 1-2 weeks after a tick bite, though not everyone will develop the distinctive rash. The rash may be accompanied by a fever, chills, and body aches. The culprit is a type of bacterium carried by tiny deer ticks. Without treatment, Lyme disease can affect the joints, nervous system, and heart.

Molluscum Contagiosum Signs: This contagious

rash shows up as one or more flesh-colored, raised bumps that are about the size of a pimple. The center of each bump has a tiny dimple. The rash usually shows up on the face, arms, and legs

Diaper Rash With Yeast Infection

Signs: This red, raised rash shows up in the groin, around the genitals, in the creases of the hips, or on the buttocks. It itches or irritates. Signs of an accompanying yeast infection are round, red spots separate from but near the main rash.

Kawasaki Disease Kawasaki disease is a very

rare and mysterious ailment that strikes children under age 5. The symptoms include a high fever, patchy rash, swelling and redness of the hands and feet, bloodshot eyes, and chapped, red lips. Without treatment, the illness can damage the heart and may be fatal. Doctors have yet to discover what causes Kawasaki disease.

• A child is brought into his pediatrician's office after developing a diffuse rash. His parents do not believe in vaccinations. You suspect that the child has developed measles. All of the following are true about measles EXCEPT:

• A. Measles is a leading cause of death in young children worldwide

• B. The classic triad is cough, coryza, and conjunctivitis

• C. Koplik spots are pathognomonic white spots that appear on the buccal cheeks

• D. A major early complication is acute sclerosing panencephalitis

• E. Since the introduction of the measles vaccine, the annual incidence dramatically decreased.

Measles is one of the most contagious infectious diseases, with a secondary infection rate of 90% in susceptible individuals

it remains one of the leading causes of death in young children worldwide, with an estimated 197,000 deaths yearly. After exposure, the incubation period lasts for 7-14 days. Patients then develop a prodrome of high fevers, often > 104° F, with the classic triad of cough, coryza, and conjunctivitis. A couple of days later, Koplik spots develop on the buccal mucosa, appearing as white spots on an erythematous base, as shown.

o A 4-month-old girl presents to the ED in extremis with rapidly developing gangrene of the extremities. All of the following are true of meningococcemia EXCEPT:

o A. The mortality rate is 5%-10%

o B. Meningitis is present in all cases of septicemia

o C. Empiric antibiotic treatment should be initiated immediately

o D. Transmission is person-to-person by direct contact via respiratory droplets

o E. Gangrene is caused by arterial occlusion

The correct answer is B Meningococcemia is caused by

the gram-negative diplococcusNeisseria meningitides. Transmission is person-to-person via respiratory droplets, often from an asymptomatic carrier. Up to 30% of teenagers and 10% of adults carry meningococci in the upper respiratory tract. The clinical presentation is variable, with 50% of patients developing meningitis only, 10% developing septicemia only, and 40% developing both. Children with meningitis are usually febrile and ill-appearing, with symptoms of lethargy, vomiting, or nuchal rigidity. Septicemia leads to capillary leak, coagulopathy, profound acidosis, and myocardial failure. Septic emboli cause arterial occlusion in the distal extremities, as shown in this infant.

An 11-year-old girl presents with raised violaceous plaques on her legs and arms that developed over the last few days. She has had a temperature of 100-101° F at home but no other complaints. Her current temperature is 100.2° F. The rest of her exam is normal. You conclude that she has Henoch-Schonlein purpura (HSP). Which of the following tests are most appropriate to perform at this point?

A. CBC, lumbar puncture B. CBC, electrolytes, stool for

occult blood, urinalysis C. CBC, electrolytes, stool for

occult blood, renal ultrasound D. CBC, head CT, lumbar

puncture, abdominal ultrasound E. CBC, abdominal ultrasound

The correct answer is B. The images shown are purpuric lesions. In this case of a healthy-appearing child with this history and physical examination, HSP is a reasonable diagnosis. HSP is a vasculitis that can affect the skin, joints, gastrointestinal tract, and kidneys. In a well-appearing child, HSP can be managed on an outpatient basis. It is helpful to check blood pressure, urine, and electrolytes to look for a glomerulonephritis. Urinalysis and blood pressure may be followed for several months to monitor kidney function. A fecal occult blood test can help rule out significant gut involvement, especially in children with pain. Intussusception is the most serious complication of HSP; if it is suspected, the child should be admitted and monitored.

A 3-year-old girl presents with a blistering rash on her face and body. Her mouth is pictured above. All of the following are true statements regarding Stevens-Johnson syndrome (SJS) EXCEPT:A. Medications, including nonsteroidal anti-inflammatory medications (NSAIDs), sulfonamides, antiepileptics, and allopurinol, are commonly accepted triggersB. Viruses, such as herpes simplex virus, Epstein-Barr virus, enteroviruses, and influenza, are accepted triggersC. Malignancy can be associated with SJSD. Bacterial etiologies include mycoplasma and group A beta-hemolytic streptococcus, among othersE. Idiopathic causes are unlikely

The correct answer is E. SJS may involve the mucous

membranes, including the eyes and gastrointestinal tract. When more than 30% of the body surface area is involved, cases are generally referred to as toxic epidermal necrolysis. Treatment is symptomatic, including treatment of superinfection and pain control. Patients with severe cases should immediately be fluid-resuscitated and treated as burn victims. Offending agents should be removed or treated. Use of steroids is controversial. Involvement of specialists, including ophthalmologists, immunologists, and burn specialists, may be indicated. Morbidity and mortality are correlated with the percentage of body surface area involved

Staphylococcal scalded skin syndrome (SSSS) is a disease that usually affects infants and young children who lack the antibodies to Staphylococcus aureus toxins that adults have. It is caused by bacterial infection by group II S. aureus that produces toxins that cause exfoliation, bullae (blister) formation and redness of skin. In children mortality is low, but can be high in adults, who will usually have a serious underlying disease that makes them susceptible to infection 

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