The Febrile Child with a Rash Flashcards
What are the subsets of fever in a child?
- Recurrent infection
- Pyrexia of unknown origin
- Fever with swelling in the neck
- Acute fever
- Fever and rash
What are the causes of recurrent infection?
- HIV infection and AIDS
- Hyposlenism and splenectomy
What are some causes of pyrexia of unknown origin?
- Infective endocarditis
- Osteomyelitis
- Collagen vascular disease
- Inflammatory bowel disease
- Neoplastic disease
- Factitious fever
What are some causes of fever with swelling in the neck?
- Cervical adenitis
- Infectious mononucleosis
- Mumps
- Thyroiditis (often no fever)
- Mastoiditis
What are some causes of acute fever?
- Upper respiratory tract infection
- Tonsilitis
- Otitis media
- Nonspecific viral infections
- Pneumonia
- Meningitis
- UTI
- Septic arthritis
- Non-infectious
What are some causes of fever and rash?
- Measles
- Rubella
- Roseola
- Scarlet fever
- Fifth disease
- Hand, foot and mouth disease
- Chicken pox
- Meningococcaemia
What are the three broad causes of fever?
- Infection
- Chronic inflammation
- Immune response
What classifies as a fever?
Oral temperature >37.5 degrees C (>37.8 in adults)
When are investigations for a fever always indicated?
When the child is <8 weeks old
Which investigations are relevant for a fever and what would they show if they highlighted cause of fever?
- FBC - raised WCC with increased neutrophil count = bacterial infection
- Throat swab - bacterial cultures (beta-haemolytic strep treat with penicillin)
- Blood cultures - culture of single organism indicates septicaemia, multiple organisms indicates contamination
- Lumbar puncture
- Chest x-ray - consolidation indicates pneumonia
- Urinalysis and culture - >10^5 cell colonies with >50 WCC, red cells and protein indicates infection
When should a fever be treated?
When it is >38.5 degrees, or below that level if the child is uncomfortable
How can fever be brought down?
- Undress the child
- Antipyretics eg. paracetamol and ibuprofen
- Sponging or tepid baths with lukewarm water to allow vasodilation
Why should aspirin not be given to children?
Because of associations with the development of severe liver disease (Reye’s syndrome)
What are the signs of tonsillitis on throat swab?
Tonsillar redness +- exudate, cervical lymphadenopathy
What are the signs of otitis media on otoscopy?
Bulging and red tympanic membrane
Which causes of fever cause macular and maculopapular rashes?
- Measles
- Rubella
- Roseola
- Scarlet fever
- Fifth disease
- Non-specific viral illnesses
Which causes of fever cause vesicular rashes?
- Chicken pox
- Hand, foot and mouth disease
Which causes of fever cause purpuric rashes?
Meningococcaemia
What are the main complications of measles?
- Otitis media (most common)
- Pneumonia, pneumonitis and tracheobronchitis
- Convulsions, encephalitis and blindness
- Subacute sclerosing panencephalitis (rare)
What are the symptoms of measles?
- Fever
- Cough
- Coryza
- Conjunctivitis
- Maculopapular rash with or without Koplik’s spots
What should be done if measles is suspected?
The local Health Protection Team (HPT) should be notified to confirm the clinical diagnosis, as measles is a notifiable disease
What is the management of measles?
- Rest, adequate fluids, paracetamol/ ibuprofen for symptomatic relief
- Vitamin A for all children <2
- Isolate for 4 days after development of the rash and avoid contact with susceptible people
When is admission of a measles patient necessary?
If they develop a serious complication of measles:
- Pneumonia
- Neurological problems eg. febrile convulsions or encephalitis
What is the incubation period for measles?
10-14 days
What is the transmission of measles?
Respiratory droplets
When is measles infective?
From the prodrome until 4 days after the rash starts
What is the prodromal phase of measles?
- Irritable
- Conjunctivitis
- Fever
Where does the measles rash usually start?
Behind the ears
What should be offered if a non-immunized child comes into contact with measles?
The MMR vaccine within 72 hours
How is diagnosis of measles primarily achieved?
- Measles-specific IgM and IgG serology (most sensitive 3-14 days after onset of rash)
- Measles RNA detection by PCR (most sensitive 1-3 days after rash onset)
What type of vaccine is the MMR?
Live attenuated
In which children is the MMR vaccine contraindicated?
Children with immunosuppression (all live attenuated vaccines are contraindicated)
What is the duration of the rash in measles?
5 days
What causes rubella?
Viral infection caused by the togavirus
What is the risk if rubella is contracted during pregnancy?
Congenital rubella syndrome
When are rubella outbreaks more common?
Around winter and spring
What is the incubation period of rubella?
14-21 days
What is the transmission of rubella?
Respiratory droplets or aerosols
When is the MMR vaccine given?
12 months
What are the symptoms of rubella?
- Fever
- Coryza
- Arthralgia
- Maculopapular rash beginning on the face and moving down the trunk, sparing the limbs
- Lymphadenopathy: suboccipital and postauricular (classic)
How is diagnosis of rubella confirmed?
Detection of rubella-specific IgM or a significant risk in rubella-specific IgG
What is the duration of the rash in rubella?
2-3 days
When are individuals infectious in rubella?
From 7 days before symptoms appear to 4 days after the onset of the rash
Is there an isolation period required with rubella?
Patients should stay away from school/ work at least 5 days after the development of the rash and avoid contact with pregnant women (particularly non-immune in their first trimester)
What are the compliactions of rubella?
- Arthritis and arthralgia (most common in adult women)
- Thrombocytopaenia
- Encephalitis
- Myocarditis
What should be done if there is clinical suspicion of rubella?
Inform the local HPT as rubella is a notifiable disease (within 3 days)
What is the management for rubella?
- Usually self-limiting that resolves within a week
- Rest
- Adequate fluid intake
- Paracetamol/ ibuprofen for symptomatic relief (aspirin avoided in children <16)
Which fetal abnormalities are caused by congenital rubella syndrome?
- Cataracts
- Sensorineural deafness
- Patent ductus arteriosus
- Brain damage
- Retinopathy
- Microcephaly
- Hydrocephalus (rubella can cause aqueductal stenosis)
- Low birth weight
- Organ dysfunction
What is the incubation period of roseola?
10 days
What causes roseola?
Human herpes virus 6
In which age group is roseola most common?
6 months to 2 years
What is the presentation of roseola?
- Initial febrile phase lasting 3-7 days, fevers can reach 40 degrees celcius
- Lethargy
- As the fever subsides a maculopapular rash (rose-pink macules with surrounding pale halos) predominantly over the trunk (may spread to face and limbs)
- Nagayama spots (papular enanthem on the uvula and soft palate)
- Diarrhea and cough
- Febrile convulsions (10-15%)
How is roseola diagnosed?
Typically clinically (high fever followed by rash)
In certain cases or severe manifestations, serologic testing or PCR for HHV6
What are some other possible consequences of HHV6 infection?
- Aseptic meningitis
- Hepatitis
Is school exclusion needed for roseola?
No
How long does the rash last in roseola?
1 day
What is the management of roseola?
- Supprotive treatment, oral hydration
- Paracetamol/ ibuprofen for symptomatic management
- Monitor for complications
What is the incubation period of mumps?
16-21 days
What is mumps?
An acute systemic infectious disease caused by an RNA paramyxovirus
How is mumps spread?
By respiratory droplets
What is the presentation of mumps?
- Flu-like prodrome
- Parotitis (usually unilateral initially and becomes bilateral), lasting 3-4 days (almost always)
- Epididymo-orchitis (usually 4-5 days after the onset of parotitis, uncommon in pre-pubertal)
- Aseptic meningitis (usually self limiting, 4-25% of cases)
- Encephalitis (rare)
- Deafness (rare)
- Pancreatitis
- Nephritis
- Arthritis
- Thyroiditis
- Pericarditis
Who should be notified about a mumps outbreak?
Local HPU
What are the investigations for mumps?
- Usually clinical diagnosis
- Need lab confirmation of salivary IgM mumps antibodies
- Can complete serum mumps IgM, IgG/ PCR
What is the management of mumps?
- Self-limiting, usually resolves over 1-2 weeks
- Rest, adequate fluids
- Paracetamol/ ibuprofen for symptomatic relief
- Apply warm/ cold packs to the parotid glands if needed
When is admission to hospital required in mumps?
- Signs of mumps encephalitis
- Development of mumps meningitis
- Following epididymo-orchitis (particularly bilateral), abnormal semen analysis, or infertility
How long should mumps patients isolate?
5 days after onset of parotitis
What are the clinical features of scarlet fever?
- Sore throat (tonsillitis)
- Fever
- Headache, fatigue, nausea, vomiting
- Blanching rash
When does the rash develop in scarlet fever?
12-48 hours after initial symptoms
What is the character of scarlet fever rash?
- Red, generalised and pinpoint (punctuate) with a rough, sandpaper texture
- Strawberry tongue
- Generally appears first on the torso
What’s typically spared in Scarlet fever?
Palms and soles of feet
What are Forchheimer spots?
Small red spots on the hard and soft palate associated with scarlet fever
What is scarlet fever caused by?
A reaction to erythrogenic toxins produced by group A haemolytic strep (usually strep pyogenes)
When is the peak incidence?
4 years old (common in 2-6 years)
What is the mode of transmission of scarlet fever?
Inhalation of respiratory droplets
What is the incubation period of scarlet fever?
2-4 days
What are the investigations for scarlet fever?
- Throat swab for group A strep
- Measurement of serum anti-streptolysin O (ASO antibodies), not useful in acute infection but may be helpful in diagnosing post infection complications
When should a throat swab be taken in scarlet fever?
- Uncertainty about the diagnosis
- Suspected scarlet fever outbreak (local HPT notified within 3 days)
- Allergy to penicillin (determine antimicrobial susceptibility)
- Regular contact with vulnerable people at high risk of complications
What is the management of scarlet fever?
- 1st line: Phenoxymethylpenicillin (penicillin V) for 10 days
- 2nd line: 0-6 months clarithromycin 10 days, 6 months-17 years azithromycin 5 days (or clarith 10 days)
How long should children with scarlet fever be excluded from school/ nursery?
At least 24 hours after antibiotic treatment
When should patients with scarlet fever follow up?
If symptoms haven’t improved within 7 days
What are the complications of scarlet fever?
- Otitis media (most common)
- Rheumatic fever (20 days after infection)
- Acute glomerulonephritis (10 days after infection)
- Invasive complications (bacteraemia, meningitis, necrotizing fasciitis etc)
What is the virus causing chickenpox known as?
Varicella zoster virus or human alphaherpesvirus 3 (HHV-3)
How does chickenpox present?
- Macules on the scalp, face, trunk and limbs which progress (12-14 hours) to papules, clear vesicles (itchy) and pustules
- Vesicles can occur on palms, soles and mucous membranes
- Shallow oral/ genital ulcers
What are the complications of chicken pox?
Secondary bacterial infection of skin lesions, pneumonia and encephalitis
How is chickenpox diagnosed?
Usually clinically, but lab tests can be used for confirmation
What is the mode of transmission of chicken pox?
Respiratory droplets, direct contact with blisters, saliva or mucus
What is the incubation period of chickenpox?
10-21 days
When is someone with chickenpox infectious?
4 days before rash onset, 5 days after the rash has appeared
What is the management of chickenpox?
Supportive
- Keep cool, trip nails
- Calamine lotion
- School exclusion (until 5 days after appearance of rash)
Which patients with chickenpox should receive VZIG?
Immunocompromised and newborn patients
If chickenpox develops in these patients, IV acyclovir should be considered
What is shingles?
A reactivation of the dormant virus in dorsal root ganglion
What are some specific signs of meningitis?
- Non-blanching rash (meningococcal)
- Stiff neck
- Photophobia
- Bulging fontanella
- Kernig’s sign
- Brudzinski’s sign
- Some children with bacterial meningitis present with seizures
Children presenting with specific signs are more likely to have bacterial meningitis
How does the non-blanching rash present?
- Petechial (macules <2mm)
- Purpuric (macules >2mm)
What are the most common causes of viral meningitis?
- Enteroviruses (coxsackie A and B viruses and echoviruses), most common cause
- HSV (usually a complication of primary genital herpes, not commonly seen in children)
What is the most common cause of fungal meningitis?
Cryptococcus neoformans (immunocompromised individuals)
Which drugs can cause drug induced meningitis?
- NSAIDs
- Trimethoprim/ sulfamethoxazole
- Amoxicillin
- Ranitidine
What is the management of suspected bacterial meningitis?
Benzylpenicillin (IV or IM)
- <1 300mg
- 1-9 600mg
- >10 1200mg
When would benzylpenicillin be withheld in someone with suspected bacterial meningitis?
If they have a history of penicillin induced anaphylaxis
What is the pre-hospital management of meningitis without a non-blanching rash?
Urgent transfer to hospital, do not give parenteral antibiotics unless urgent transfer to hospital isn’t possible
Empiric antibiotics depend on availability/ local policy:
- Benzylpenicillin
- Cefotaxime
- Chloramphenicol
What are the warning signs for bacterial meningitis that warrant senior review?
- Rapidly progressive rash
- Poor peripheral perfusion
- Low or high resp rate or low or high pulse rate
- pH <7.3 or WBC <4*10^9/L or lactate >4 mmol/L
- GCS <12 or a drop of 2 points
- Poor response to fluid resuscitation
When should LP be delayed in suspected meningitis?
- Severe sepsis or rapidly evolving rash
- Severe respiratory/ cardiac compromise
- Significant bleeding risk
- Signs of raised ICP
What is the management for patients with bacterial meningitis in hospital?
- IV access (bloods + blood cultures)
- IV abx: 3 months - 50 years ceftriaxone/ cefotaxime, >50 cefotaxime + amoxicillin
- IV dexamethasone (avoid in meningococcal septicaemia/ immunocompromised, mainly for adults)
What is the antibiotic management of meningitis in <3 months?
IV cefotaxime + amoxicillin (or ampicillin)
What is the antibiotic management for meningococcal meningitis in hospital?
IV benzylpenicillin or cefotaxime (or ceftriaxone)
What is the antibiotic management for meningitis caused by listeria?
IV amoxicillin (or ampicillin) + gentamicin
What antibiotics should be given in bacterial meningitis if the patient is allergic to penicillin or cephalosporins?
Chloramphenicol
When should meningitis contacts be offered prophylactic antibiotics?
If they have had close contact within 7 days of meningitis onset
What are the prophylactic antibiotics given to meningitis contacts?
Oral ciprofloxacin or rifampicin (ciprofloxacin is the drug of choice)
When should the meningococcal vaccination be offered to contacts?
When serotype results are available, including booster doses to those who have had the vaccine in infancy
What are the viral causes of meningitis?
- Non-polio enteroviruses eg. coxackie virus, echovirus
- Mumps
- HSV, CMV, herpes zoster viruses
- HIV
- Measles
What are the risk factors for viral meningitis?
- Patients at the extremes of ages (<5 and the elderly)
- Immunocompromised
- IVDU
What would seizures suggest in a suspected meningitis patient?
Meningoencephalitis
What is the management of meningitis while awaiting LP results, with suspicion of bacterial cause?
Broad-spectrum abx with CNS penetration eg. ceftriaxone and acyclovir IV
What is the management of viral meningitis?
- Supportive with symptoms resolving over 7-14 days
- Acyclovir if the patient is suspected of meningitis secondary to HSV
What bacteria causes meningococcal infection?
Neisseria meningitidis
Gram -ve intracellular diplococcus
Which bacteria most commonly cause meningitis in neonates?
- E.coli
- Group B strep
What is the prophylactic dose of ciprofloxacin given to meningitis contacts?
Single dose of oral ciprofloxacin
What is the prophylactic dose of rifampicin given to meningitis contacts?
Oral twice a day for 2 days
Why should NSAIDs not be given to a patient with chicken pox?
NSAIDs can increase the risk of necrotising fasciitis
