Fever with rash Flashcards
A 3-year-old boy presents for his second visit to see you. Two days
ago he was seen with a 4-day history of intermittent fever spiking
to 40°C and irritability. His examination at that time was
remarkable only for dry oral mucosa and cracked lips. You advised
the mother to give 4 oz of an electrolyte solution in the clinic and
was sent home with instructions for symptomatic care.
Since then the fever has not subsided and mother noted her child
to cry when walking and avoids placing weight on his soles. The
mother denies any sick contacts. The patient does not have a
cough, nausea, vomiting ,or diarrhea. He has been eating and
drinking, and the mother states that he is still producing urine.
Physical Examination
Vital Signs: BP 90/56, HR 136, RR 24, Rectal Temp 38.8, Oxygen
Sat. 99% on Room air; weight 18 kg
General: The patient is sitting on his mother’s lap; awake and
alert, good eye contact; cries if he is made to stand on his feet
HEENT: Atraumatic/normocephalic; PERRL, bilat conjunctival
injection, no discharge. The perioral area is swollen and
erythematous and the lips are cracked. There is pharyngeal
erythema with no exudate, vesicles, or lesions seen. MMM. No
LAD upon palpation. Neck is supple; there is no nuchal rigidity.
Resp: Lung sounds clear to auscultation. No
wheezing/rales/rhonchi.
Chest: Sandpaper rash on chest and upper abdomen which is
resolving per mother. No vesicles or lesions.
CV: RRR, no murmurs, rubs, or gallops; pulses 2+ and equal in all
ext.
ABD: Soft, nontender/nondistended. Positive bowel sounds, no
flank tenderness.
EXT: palms and soles are swollen, erythematous, tender to
palpation. No vesicles or lesions present. Cap refill less than 2 sec.
GU: There is an erythematous rash and peeling skin on the groin
and penis. Testes descended.
Neurological: Awake, alert; able to ambulate but cries when
weight is placed on soles.
CBC
Hgb 11, Hct 0.33, WBC 11.0, Neuts 0.65, Lym 0.22, Plt 560
MCV 75, MCH 20, MCHC 25, RDW 15
Urinalysis
Light yellow, clear, sp gr 1.010, pH 6.0, wbc 8-10, rbc 0-1, few
epithelial cells, few hyaline casts, Leukocyte esterase positive,
nitrite negative
2D echo
Echocardiogram showed a normal ventricular size and function
and no effusion. The coronary arteries were well visualized and
were of normal size.
15 L ECG
100 bpm, no axis deviation, no PR prolongation, no QRS widening,
no atrial or ventricular hypertrophy, no ST changes, no T wave
inversions, no accessory waves or ectopic beats; no previous EKG
available for comparison
CXRay
Mild hyperinflation, no focal opacity
What is the other name for Kawasaki disease?
mucocutaneous lymph node syndrome
What are the criteria for kawasaki disease?
Incomplete
Criteria
1 Conjunctival injection, usually non-exudative
2 Cervical lymphadenopathy of at least 1.5 cm diameter
3 Lip and oral cavity involvement such as swollen or dry
lips, erythematous tongue, or pharyngeal erythema
4 Trunk or genital area erythema
5 Hand or foot erythema, swelling, or desquamation
Give differentials for fever with rash
Measles, EBV,
adenovirus
Toxin mediated
illness (GAS like
scarlet fever and
TSST)
Drug reactions
(SJS/TEN and EM)
Systemic onset JIA
Mercury
hypersensitivity
_____________________________________________________
1. Measles, EV, Adenovirus
Has mucocutaneous lesions with rashes (has both
enanthems and exanthem)
Lacks changes in extremities found in KD
Clinical features are different (cough, colds,
coryza of measles, HSM of EBV, etc.)
- Toxin mediated illness (GAS like scarlet fever and
TSST)
Enanthem and exanthem
Generally lacks ocular and articular involvement, has preceding GAS infection
- Drug reactions (SJS/TEN and EM)
-Desquamating lesion
-Precedent drug intake - Systemic onset JIA
-Has same skin lesion with fever
-More indolent course - Mercury hypersensitivity
-Same desquamating lesion and rashes
-Prior intake of mercury
What are the diagnostics for Kawasaki disease?
Diagnostics
Echo
12L ECG
CBC
Other examinations: urinalysis, AST, albumin
What are the lab findings suggestive of Kawasaki disease?
Additional findings suggestive of Kawasaki
● Albumin<3
● Anemia
● WBC>12,000
● Elevated ALT
● Platelets>450,000 after 7 days of fever
● Pyuria
How is Kawasaki disease managed?
Admit the patient for treatment and arrange for an
echocardiogram
Start ASA high dose, or start IVIG
Monitor acute phase reactants (ESR, CRP)
Continue supportive treatment as an outpatient and have the
patient follow up in one week for an echocardiogram
Advise the patient’s mother to continue with aspirin and
follow up in 2 days
What are the complications of Kawasaki disease?
Complications
Coronary artery aneurysm, myocardial infarction, thrombocytosis,
sterile pyuria, and gall bladder hydrops.
Continuing care
2D echo at 4-6 weeks after discharge, then yearly thereafter
Anthropometrics monitoring
Nutritional counselling
Injury prevention
What are the other differentials for fever with rash?
VIRAL EXANTHEMS
1. Measles (p.54)
2. Rubella (p.55)
3. Roseola infantum (p.56)
4. Chickenpox (p.57)
5. Erythema infectiosum (p.56)
6. Hand-foot-mouth disease (p.64)
Meningococcemia
What is the cause of meningococcemia?
Neisseria meningitides
§ Commensal of nasopharynx
IP: 3-4 d (2-10d)
Transmission:
- Close contact through aerosol droplets or contact with
respiratory secretions
- Humans are the only natural reservoir
Epidemiology
- Serogroups A,B,C,W,Y
- Highest rate of disease in infants < 1 yo
- Carriage of bacteria during adolescence and young adulthood
What are the risk factors of meningococcemia?
Risk factors:
1. Respiratory viral infections (flu)
2. Male
3. Smoking, marijuana, binge drinking
4. Crowded living (dormitories)
5. Underlying chronic ds
6. Low SE status
What is the pathophysiology of meningo?
Patho
- NM colonizes nasopharynx –> NM secrete protease degrading
IgA on mucosa –> bacterial resistance to phagocytosis –>
inflammatory cascade sec to LPS
- severe ds secondary to capillary leak syndrome, DIC, prolonged
myocardial dysfunction –> MOF –> death
- Procoagulant state
- highest level of Ab protective at birth and adults
- lowest Ab level at 6mos-2yo: highest ds incidence
What are the clinical manifestations of meningo?
Suspect case definition
An illness with sudden onset of fever (>38.5C rectal or >38C axillary) and one or more of the ff:
*neck stiffness
bulging fontanel
non-blanching rash (petechiae, purpura)
Probable Case definition
A suspect case plus one or more of the ff:
Clinical diagnosis of meningococcal disease by the attending physician
*clinical diagnosis of meningococcal disease by the attending physician
*gram(-) diplococci in the CSF
*turbid CSF
*increased cell count in CSF
Confirmed case definition
A suspect or probable case with one or more of the ff:
*isolation of N. meningitidis from a sterile site (CSF or blood)
*identification of N. meningitidis DNA from a sterile site (CSF or blood)
*positive latex agglutination test for N. meningitidis (CSF)
Most death occur w/in 48hrs
Case fatality rate 5-10%
Most cases asymptomatic carriage in nasopharynx
Consider even in a <2d fever with a very toxic looking child
1. Meningococcal meningitis (30-50%) – most common presentation of invasive ds
- Fever, headache, photophobia, nuchal rigidity, bulging fontanel, lethargy, vomiting
- Acute meningococcal septicemia – nonspecific s/sx: fever, irritability, lethargy, respiratory sx, vomiting, sore throat, diarrhea. Followed by cold hands and feet, abN skin color, prolonged CRT, non-blanching petechial rash
- Fulminant meningococcal septicemia – rapid
progression from non-specific sx to septic shock
- Prominent petechiae and purpura fulminans w/in
hours
- Diffuse vasculitis (skin, heart, adrenals, mucus mem)
- N sensorium to confusion
- DIC
- Rash: fine MP –> non-blanching petechial –>
prominent petechiae and purpura - Waterhouse-Friderichsen syndrome – fulminant cases. Diffuse adrenal hemorrhage leading to adrenal failure
- Occult meningococcal bacteremia – fever only, rare
- Chronic meningococcemia – rare. Fever, arthralgia, headache, splenomegaly, MP or petechial rash x 6-8wks. Non-toxic appearance
What are the prognostic factors of meningo?
Prognostic factors
A. Poor
a. Hypo or hyperpyrexia
b. Hypotension or shock, sz
c. Purpura fulminans
d. Leukopenia, thrombocytopenia, acidosis
e. High endotoxin and TNF-a
B. Poorer
a. Petechiae <12h before admission
b. No meningitis
c. Low or N ESR
Diagnostics of meningo?
Dx
1. CSF analysis, GS/CS – gram (-) diplococci. Gold standard
2. PCR
3. Latex agglutination test -
4. CBC – high/low WBC, elev neu, band forms, low RBC,
dec plt
5. UA – inc ptn, RBC
6. Elev ESR, CRP
7. ABG, e’, BUN, Crea, PT/PTT
8. CXR – r/o PN, ARDS
9. Echo – r/o myocardial dysfunction, pericarditis
10. MRI – ID deep muscle and bone involvement
what is the management for meningo?
Mgt
1. Empiric abx: 3rd gen ceph
2. DOC: x5-7d
a. Penicillin G 300,000 U/kg/d in 4-6 div doses
(inc resistance to penicillin)
b. Ceftriaxone 100mkd 1-2x/d
c. Cefotaxime 200-300 mkd q6-8h
3. Supportive – ET and MV, IVF, correction of e’ abN, ICP
4. CS – for severe septic shock due to adrenal
insufficiency
Complications of meningo?
Complication
1. Adrenal hemorrhage
2. Endophthalmitis
3. Arthritis
4. Endocarditis, pericarditis, myocarditis
5. PN, lung abscess, pneumonitis
6. Renal infarcts
7. Focal skin infarct – most common: amputation,
scarring, skin grafting
8. Deafness: most freq neuro sequelae
9. Brain abscess, sz, neuro impairment
How is meningo prevented?
Prevention
1. Household, school, or day care contacts during the 7d
before onset of illness should receive prophylaxis
2. Prophylaxis for medical personnel intimately exposed
(intubation, suctioning)
a. Rifampicin 10mkdose q12h x 4doses;
5mkdose for <1mo
b. Ceftriaxone 125mg IM SD for <15 yo, 250mg
SD for >15yo
c. Ciprofloxacin 500mg po SD for >18yo
3. Meningococcal vaccination for high risk population
a. Quadri vax Men ACWY-D 2 doses 12 weeks
apart @9-23mos
What is the common vasculitis of childhood?
CH 515: HENOCH-SCHONLEIN PURPURA
- Small vessel vasculitis
