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Hot Spots (Or Red Rashes With Fever) Yasmin Tyler-Hill, M.D. Clinical Assistant Professor Department of Pediatrics Morehouse School of Medicine

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Objectives Recognize rashes that are included in the differential diagnosis of Rheumatologic diseases Differentiate common and uncommon but serious diseases that present with fever and rash

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So, What Hot Spots Do We Visit Kawasakis Stevens Johnson Rocky Mounted Spotted Fever Measles Group A Strep/Toxic Shock Syndrome Henoch Schoenlein Purpura Roseola

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Case #2 20 month old female presents to your office with a 5 day history of fever and irritability. She was seen in the local ER 3 days ago and was given Amoxicillin for an ear infection. Mom stopped the amoxicillin this morning secondary to a rash. What do you want to know?

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Case #1 HPI: Temperature up to 103. Mother is using Tylenol and Motrin with relief, but the fever returns. Child also has been more irritable than usual, difficult to console. He has been drinking less with decrease urine output

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Case #1 ROS : Fever (104) Irritability Decreased PO intake Decreased UOP Rash Vomited x 1 NO diarrhea NO SOB NO pain No sick contacts FH Sickle cell trait Asthma SH Lives with mom and dad Only child Attends daycare Immunization UTD

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Case #1 Physical Exam Vital Signs: T: 39 HR: 138 RR: 30 BP: 90/50 HEENT: NCAT, slightly dry / cracked MM, injected conjunctiva, normal turbinates, TMs erythematous bilaterally, OP with erythematous tongue and white tonsilar exudate Neck- bilateral cervical lymphadenopathy (1.5 cm on right and 0.5 cm on the left)

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Case #1 Physical Exam (Cont.) Lungs: CTA bilaterally, no wheezes, no rales CV: Tachycardic, normal rhythm, pulse 2+ Abdomen: soft, NTND, good bowel sounds Skin: red, blanching, slightly raised, polymorphous rash over her extremities Neurological: irritable, difficult to console Genitalia: normal female, desquamation of the area Extremities/ MS- FROM, puffy hands, good tone

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Case 1# Physical Exam

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Case #1 Laboratory Evaluation WBC 15,000 20 bands, 52 neutrophils, 22 lymph, 6 monocytes H/H 9.7/ 30. Platelets 700,000 UA sp.grav 1.030, ketones 2+ Electrolytes- normal Blood Culture, Urine culture, ? CSF culture

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Kawasaki Disease Epidemiology Affects all races, seen throughout the world (Asian descent affected more often) 80% in children less than 5, rarely teenager and adults Boys: Girls = 1.5:1 In US about 3000 children hospitalized annually 0.4%-2.0% mortality rate 20-25% with cardiac complications

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Case #1 Diagnosis and Treatment Diagnosed with Kawasaki disease Kawasaki disease is a generalized, acute vasculitis of unknown cause Received IVIG Started on Aspirin Cardiac Echo Improved within 12 hours

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Kawasaki Disease: Clinical Diagnosis FEVER plus 4 of the 5 Bilateral, non exudative conjunctival injection injected or fissured lips, injected pharynx, or strawberry tongue erythema of palms or soles, edema of hands or feet, or periungual desquamation Polymorphous exanthem Acute, nonsuppurative cervical lymphadenopathy (at least one node 1.5 cm in diameter)

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Kawasaki Disease: Evaluation Three phases Although no specific test, abnormal labs seen are leukocytosis, elevated erythrocyte sedimentation rate, thrombocytosis, and sterile pyuria. Unknown cause Morbidity and Mortality related to coronary artery thrombosis in 20- 25% of children

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Kawasaki Disease: Management IVIG High dose Aspirin Cardiac Echo Follow -up

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Case #2 This 8 year old girl developed upper respiratory symptoms with fever, cough, tachypnea, and malaise several days before a purulent conjunctivitis, erosive oral mucositis, and blistering skin rash. The cutaneous lesions were relatively limited, and the oral lesions and conjunctivitis began to improve 3 to 4 days later. Rapid diagnostic tests for Mycoplasma pneumoniae were positive. Interestingly, her mother had a history of pneumonia treated with oral antibiotics several weeks earlier, and her sister developed a cough and mild but similar rash several days after the patient was hospitalized.

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Purulent conjunctivitis with edematous lids and conjunctival hemorrhage, cheek and chin vesicles, intranasal and lip erosions

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Diffuse red macules many with central necrotic bulla and erosions and associated conjunctivitis and mucositis

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Bullae and erosions on lips, mouth, and scattered on skin

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Diffuse red papules and plaques some with central necrotic bullae, erosions of the conjunctivae and oral mucosa

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Stevens-Johnson Syndrome Cell mediated hypersensitivity response Clinical Presentation Multiorgan/systmem involment eye, kidney, liver Skin and mucosal Precipitating Factors Drugs Abx & anticonvulsants Infective agents Mycoplasma &herpes simplex Management

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A diffuse scarlatiniform eruption developed on this 4-year-old boy who demonstrates his strawberry red tongue and red and fine scaly papular rash. A throat culture was positive for Group A beta-hemoplytic Streptococcus

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A healthy 6-year-old boy developed a diffuse papular eruption in association with headache, sore throad, and fever. His throat culture was positive for Group A beta-hemolytic streptococcus, and he improved within several days on oral amoxacillin.

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Peeling with minimal underlying erythema This 4-year-old boy with a history of atopic dermatitis was treated for right sided mastitis with topical mupirocin ointment. He subsequently developed a disseminated red sand paperlike eruption. A throat culture was positive for Group A beta-hemolytic streptococcus, and he was treated with oral erythromycin because of a history of penecillin allergy. He subsequently developed widespread desquamation with the most prominent lesions on the hands and feet.

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This 8-year-old girl developed a red papular eruption on her lower extremities and a disseminated sandpaper-like rash 3 days after the onset of a sore throat with a positive Group A beta hemolytic streptococcus culture. She also had a strawberry tongue with a white membrane and prominent red papillae poking through the coating.

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Group A Streptococcal Infections Clinical Manifestations Respiratory Skin Other Sequelae Management Diagnosis Treatment

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Proposed Case Definition for the Streptococcal Toxic Shock Syndrome Isolation of group A streptococci Hypotension: systolic blood pressure 90 mm Hg in adults or