Pyrexia + Rash Flashcards
What are the differentials for pyrexia and a rash?
- Disseminated intravascular coagulation, acquired aplastic anaemia
- Bacterial infection i.e. meningococcal/pneumococcal septicaemia
- Viral infection i.e. enterovirus and influenza
- Vasculitis e.g. HSP
- Accidental or non-accidental injury
- Immune thrombocytopenic purpura (ITP)
- SLE
- Deficiency in Vit C, K, B
- Leukaemia
- Inherited condition of no platelets i.e. Wiskott-Aldrich syndrome and bleeding disorders i.e. vW disease
- SEs of meds, immunisation related
- Felt tip
What questions would you want to ask about pyrexia and rash?
- Have they ever had marks like this before?
- Have they had the usual amount of energy or looked pale lately?
- Do they bruise easily or have heavy nosebleeds?
- Any meds/allergies
- Who lives at home, are you related, are you fit and well?
- Any antenatal problems? Birth weight?
- Ask about diet
- Vaccination hx
What are the signs/symptoms of meningococcal/pneumococcal septicaemia?
- Signs of CV compromise i.e. HR, RR, CRT, BP, neurological status, cool mottled perfusion
- No generalised lymphadenopathy, may have cervical lymphadenopathy if had concurrent URTI which often causes the nasal portal for infection
- Rash found in any distribution may have petechiae, purpura and ecchymosis
- Beware the child may have no signs of shock initially and look alert and playful
What are the signs and diagnosis of a virus I.e. influenza?
- No sign of CV compromise I.e. prolonged CRT, decreased BP
- Signs of viral illness I.e. URTI, pyrexia with raised HR + RR
- Achy joints
- Petechiae but no purpura and no bruising
- No hepatosplenomegaly
- May have cervical lymphadenopathy but no generalised unless glandular fever
- No sign of anaemia
What are the signs and diagnosis of ITP?
- No sign of CV compromise, lymphadenopathy of hepatosplenomegaly
- Petechiae, purpura and ecchymosis found over any bit of body
What are the signs and diagnosis of HSP?
- No generalised lymphadenopathy, May have cervical with concurrent UTI
- Rash found mainly over lower limbs and buttocks, can extend to upper limbs
- Rash mainly found on the extensor surfaces, mainly palpable purpura, ecchymosis
- Swollen, painful joints
- Swollen testes
- Abdominal pain
- Can cause IgA nephritis - haematuria and proteinuria that can develop to nephrotic syndrome
What are the signs and diagnosis of leukaemia?
- Pallor over mucous membranes
- Generalised lymphadenopathy
- Hepatosplenomegaly
- Petechiae, purpura, ecchymosis over any part of body
- Signs of CV compromise if very anaemia or have associated sepsis which can occur due to poorly functioning WBC
What are the signs and diagnosis of NAI?
- Unusual pattern of marks
- CV compromise depends on severity of internal injury
What investigations do you want to do for fever + rash?
- FBC, platelets
- CRP, blood cultures
- U+Es, urinalysis, PCR
What investigations do you do for HSP in children?
- Often renal involvement e.g. increased PCR, blood, protein
- Children will have their BP and urine checked for renal involvement for up to a year after rash resolves
- Rash doesn’t scar
What are the differentials for painful testicles?
- HSP - scrotal oedema
- Intussusception
- Testicular torsion
What is intussusception?
When one part of the bowel invaginate into the lumen of the adjacent bowel, usually around the ileo-caeca, region. Usually affects infants 6-18 months old. Boys are affected 2x as often as girls.
What are the features of intussusception?
- Paroxysmal abdominal colicky pain
- Child draws their knees up and turns pale during pain
- Vomiting
- Bloodstained stool - ‘red currant jelly’ (late sign)
- Sausage shaped mass in RUQ
What are the investigations for intussusception?
USS shows ‘target sign’ (looks like a bullseye)
What is the management for intussusception?
- Most kids treated via reduction by air insufflation (simply by blowing air into the bowel)
- If above fails or peritonitis occurs - surgery
What is Meckel’s diverticulum?
Congenital diverticulum of small intestine. Rule of 2s:
- Occurs in 2% of population
- 2 feet from ileocaecal valve
- 2 inches long
What is the presentation of Meckel’s diverticulum?
- Usually asymptomatic
- Abdo pain mimicking appendicitis
- Rectal bleeding: commonest cause of painless massive GI bleeding needing transfusion in children 1-2yrs old
- Intestinal obstruction
What is the management of Meckel’s diverticulum?
Removal of narrow neck or symptomatic. Either wedge excision or small bowel resection and anastomosis.
What is testicular torsion?
Twisting of spermatic cord (due to tunica vaginalis all around the testes) - causes testicular ischemia and necrosis. Most common in males aged between 10-30yrs (peak incidence 13-15yrs).
What are the features of testicular torsion?
- Pain usually severe and sudden onset
- N+V
- Examination - swollen, tender testes retracted upwards, skin may be reddened
- Cremateric reflex is lost
- Elevation of testis doesn’t ease pain (Prehn’s sign)
What are the differentials for testicular torsion?
- Epididymorchitis
- Idiopathic scrotal oedema
What is the management for testicular torsion?
- Treatment via urgent surgery - both testes should be fixed as condition of bell clapper testes is often bilateral
- If there is any doubt, refer without delay: <2yrs of age go to children’s A+E, >2yrs of age then local A+E
- Keep child NBM until surgical review
What conditions cause anaemia by RBCs being destroyed?
- G6PD
- Sickle cell
- Thalassaemia
- Drug/viral induced haemolytic anaemia
- Physiological anaemia of the newborn
What conditions cause anaemia by RBCs being lost?
- Haemorrhagic disease of the newborn
- IBD
- Cows milk protein enteropathy
- Clotting disorders
- Menstruation
What conditions cause anaemia by RBCs being produced too slowly?
- Blackfan diamond syndrome
- Transient aplastic anaemia
- IDA
- Chemotherapy
- Leukaemia
Describe IDA in children
Very common in children mostly secondary to nutrition - microcytic hypochromic cells.
What are the types of cells involved in thalassaemia?
Microcytosis, hypochromia, anisocytosis, poikilocytosis (spiculted tear-drop and elongated cells) + nucleated
How does sickle cell disease affect children?
- 1 in 2000 babies in UK.
- It is autosomal recessive with overdominance characterised by RBCs that can change to a sickle shape and become stuck in small blood vessels. This can cause pain and damage to baby’s body, serious infection or even death.
- SCD presents after 6 months of age
- High mortality in first 5 years due to infection caused by pneumococcus, haemophilius or salmonella
- As part of NHS blood spot screening programme all newborn infants born in UK are screened for SCD.
What types of childhood cancers are there?
- Wilms tumour (nephroblastoma)
- Rhabdomyosarcoma
- Optic glioma (Juvenile Pilocytic Astrocytoma)
- Retinoblastoma
- Neuroblastoma
What tumours cause a head tilt?
- Retinoblastoma
- Optic glioma
- Medulloblastoma
- Rhabdosarcoma
Why do some cancers cause a head tilt?
Any condition which causes diplopia and visual loss can present with squints or head tilt as the child tries to compensate. This can either be due to localised disease as seen in retinoblastoma, rhabdosarcoma, optic glioma or due to increased ICP affecting the 6th nerve as in medulloblastoma and again optic glioma. ALL can present with facial nerve palsy and an FBC should be done in children presenting with a Bell’s palsy.
What are the features of Wilms tumour (nephroblastoma)?
- Most common <5yrs
- Often associated with other syndromes e.g. Beckworth-Wiedemann Syndrome (larger than normal internal organs)
- It presents with a lump in the abdomen, often seen as child jumping up nappy sizes, blood in urine
What are the features of rhabdomyosarcoma?
Can present with bulging of the eye but is a soft tissue sarcoma so does not affect the retina. If in the bladder, can also present with blood in urine and obstruction.
What are the features of optic glioma (Juvenile Pilocytic Astrocytoma)?
- Occurs in the optic nerve or around the optic chiasm and is a brain tumour
- Presentation can be vision loss, proptosis, headaches, N+V, growth delay due to compression of hypothalamus and pituitary gland.
- It is associated with Neurofibromatosis type 1
What are the features of retinoblastoma?
- Tumour on retina - white reflex
- Most commonly affects children <5yrs
- Can be associated with RB1 gene
What are the features of neuroblastoma?
- Cancer of neural crest cells
- Most commonly children <5yrs
- Most commonly in adrenal glands or in the nerves running alongside the spinal cord in the neck, chest, abdomen
