Rashes and Fever by niusheng11

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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

• Recognize rashes that are
  included in the differential
  diagnosis of Rheumatologic
• Differentiate common and
  uncommon but serious diseases
  that present with fever and rash
…So, What Hot Spots Do
We Visit
 • Kawasaki’s
 • Steven’s Johnson
 • Rocky Mounted Spotted Fever
 • Measles
 • Group A Strep/Toxic Shock
 • Henoch Schoenlein Purpura
 • Roseola
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?
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
Case #1
• ROS:                 • FH
  • Fever (104)          • Sickle cell trait
  • Irritability         • Asthma
  • Decreased PO       • SH
                         • Lives with mom and
  • Decreased UOP          dad
  • Rash                 • Only child
  • Vomited x 1          • Attends daycare
  • NO diarrhea
                       • Immunization
  • NO SOB
                         • UTD
  • NO pain
  • No sick contacts
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, TM’s 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)
Case #1 Physical Exam
• Lungs: CTA bilaterally, no wheezes,
  no rales
• CV: Tachycardic , normal rhythm,
  pulse 2+
• Abdomen: soft, NTND, good bowel
• Skin: red, blanching, slightly raised,
  polymorphous rash over her
• Neurological: irritable, difficult to
• Genitalia: normal female,
  desquamation of the area
Case 1# Physical Exam
Case #1 Laboratory
• 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
Kawasaki Disease
• Epidemiology
  • Affects all races, seen throughout the
    world (Asian descent affected more
• 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
Case #1 Diagnosis and
• Diagnosed with Kawasaki
    • Kawasaki disease is a generalized,
      acute vasculitis of unknown cause
•   Received IVIG
•   Started on Aspirin
•   Cardiac Echo
•   Improved within 12 hours
Kawasaki Disease:
Clinical Diagnosis
• FEVER plus 4 of the 5
  • Bilateral, non exudative conjunctival
  • injected or fissured lips, injected
    pharynx, or strawberry tongue
  • erythema of palms or soles, edema of
    hands or feet, or periungual
  • Polymorphous exanthem
  • Acute, nonsuppurative cervical
    lymphadenopathy (at least one node
    ≥1.5 cm in diameter)
Kawasaki Disease:
• Three phases
• Although no specific ―test‖,
  abnormal labs seen are leukocytosis,
  elevated erythrocyte sedimentation
  rate, thrombocytosis, and sterile
• Unknown cause
• Morbidity and Mortality related to
  coronary artery thrombosis in 20-
  25% of children
Kawasaki Disease:
•   IVIG
•   High dose Aspirin
•   Cardiac Echo
•   Follow -up
      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.
Purulent conjunctivitis with edematous lids and conjunctival hemorrhage, cheek and chin
vesicles, intranasal and lip erosions
Diffuse red macules many with central necrotic bulla and erosions and associated
conjunctivitis and mucositis
Bullae and erosions on lips, mouth, and scattered on skin
Diffuse red papules and plaques some with central necrotic bullae, erosions of the
conjunctivae and oral mucosa
Stevens-Johnson Syndrome

 • Cell mediated hypersensitivity
 • Clinical Presentation
     • Multiorgan/systmem involment –eye,
       kidney, liver
     • Skin and mucosal
 • Precipitating Factors
     • Drugs –Abx & anticonvulsants
     • Infective agents –Mycoplasma
       &herpes simplex
 • Management
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
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.
        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.
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
Group A Streptococcal
• Clinical Manifestations
  •   Respiratory
  •   Skin
  •   Other
  •   Sequelae
• Management
  • Diagnosis
  • Treatment
Proposed Case Definition for the
Streptococcal Toxic Shock
     • Isolation of group A streptococci
     • Hypotension: systolic blood pressure 90 mm
       Hg in adults or <5th percentile for age in
 • AND
     • Two or more of the following signs
         − Renal impairment
         − Coagulopathy:
         − Liver involvement
         − Adult respiratory distress syndrome
         − A generalized erythematous macular rash that
           may desquamate
         − Soft-tissue necrosis, including necrotizing
           fascitis or myositis, or gangrene
   Case # 3

This healthy 10-year-old girl developed purpuric papules consistent with a
leukocytoclastic vasculitis on her distal extremities several weeks after a viral
upper respiratory infection. She had migratory swelling of the hands and feet and
intermittent crampy abdominal pain. Her urinalysis and blood pressure were
normal. A skin biopsy from a lesion on the top of the foot showed a
leukocytoclastic vasculitis, and direct immunofluorescence demonstrated
deposition of IgA around dermal blood vessels.
         Case # 4
A 6-year-old boy comes to your office because of migratory pain and swelling of his joints. Three
days ago he experienced pain and swelling of his right hand and knee. The following day, the pain
and swelling had spread to his right ankle. He complains now only of right ankle and lower back
pain. The joints were warm, but no erythema was noted. The child has been healthy, with no history
of fever, runny nose, cough, vomiting, sore throat, or diarrhea. He was bitten by a tick 4 months
ago. There is no family history of arthritis.
Physical examination reveals a friendly boy in no obvious distress. His vital signs, including blood
pressure, are normal, as are the results of his entire examination, except for marked swelling,
erythema, and tenderness of the right ankle, which has limited range of motion. There is tenderness
on palpation of the sacroiliac joints, but no obvious swelling or limitation of motion is appreciated.
There are no rashes.
Laboratory testing reveals: white blood cell count, 13.2 x 109/L (13.2 x 103/mcL); hemoglobin, 8.93
mmol/L (14.4 g/dL); platelet count, 306 x 109/L (306 x 103/mcL); erythrocyte sedimentation rate, 11
mm/hr; normal findings on urinalysis; negative throat culture, anti-streptolysin O titer, anti-DNAse B
titer, Lyme titer, mononucleosis test, and Epstein-Barr titers. Radiographs of the right ankle and
lumbosacral spine show no bony abnormalities.
       Case # 4 (con’t.)

Upon his return to the office, the boy was noted to have a purple, papular rash on his
buttocks and lower extremities and was experiencing severe abdominal pain and
swelling of his left elbow, a constellation of findings characteristic of Henoch-Schöenlein
purpura (HSP).
  • Leucocytoclastic vasculitis
  • Clinical Presentation
    − Rash, angioedema
    − Arthritis or arthralgias
    − GI
       – 50% of affected children
       – Colicky abd pain, GI bleeding, rarely
    − Kidney disease
       – 25-50%
       – Hematuria –endstage renal disease
  • Management
      Case # 5

A healthy 14 month old developed a red papular morbilliform eruption after 3 days of
high fever without a source. The rash begin at his head and spread distally. The rash
cleared in the same manner. The asymptomatic rash appeared as he deffervesced and
lasted less than 24 hours.
      Case # 6
A 9-month-old girl is brought to the clinic because of worsening fever and rash. Three
days ago, she developed a fever of 38.8°C (101.8°F) and pinpoint flesh-colored "bumps"
on the abdomen. The rash soon turned red and quickly spread to the entire body, but it
was not pruritic. The following day she developed clear rhinorrhea and a cough severe
enough to cause posttussive emesis. The fever persisted for the next 2 days despite
administration of ibuprofen. The increasing irritability and fever of 40.0°C (104°F)
prompted her mother to bring her to the clinic. The child’s appetite is poor, but she does
drink, and her urine output has not diminished. There is no diarrhea. Her mother denies
administering any medication other than ibuprofen. The child has been healthy
previously, and her mother is unaware of any known illness contacts. She has received
her primary immunization series for diphtheria, tetanus, pertussis, polio, Haemophilus
influenzae type b, and hepatitis B. Of note, she and her family traveled cross-country by
automobile 2 weeks ago.
    Case mealses
Physical examination reveals an irritable but consolable infant who has a red rash
consisting of raised spots and flat, confluent patches (Fig. 1 ). She has a
temperature of 38.3°C (101.8°F), respiratory rate of 42 breaths/min, and pulse of
152 beats/min. Discrete, intensely red, raised lesions extend over the face (Fig. 2 ),
trunk, and extremities. Flat, red spots appear on the palmar surfaces (Fig. 3 ). No
blisters or small, purple hemorrhages of the skin are present. Examination of the
head shows conjunctival injection without discharge; clear rhinorrhea; two grayish-
white, pinpoint, elevated spots on the right buccal mucosa; and palpable, mobile
lymph nodes in the posterior cervical regions. Auscultation of the chest
demonstrates bilateral clear breath sounds and normal S1 and S2 heart sounds
without a murmur. Findings on abdominal, genitourinary, and neurologic
examinations are unremarkable.
  • Epidemiology
     − Occurs in unimmunized preschoolers and teens
       missing 2nd immunizaation
  • Clinical Presentation
     − Incubation stage (10-12 days)
     − Prodromal stage (3-5 days)
         – Koplick spots, conjunctivits, coryza, fever,
     − Exanthem Stage
         – Red macular papular rash, high fever
  • Complications
        – Pneumonia, croup, OM, acute and subacute
  • Transmission
        – Highly contagious
Rocky Mounted Spotted Fever
This 9 year old boy developed a red partially blanching papular eruption on his hands
and feet including his palms and soles that progressed to the trunk over 3 days. He had
a severe headache, high fever, arthralgias and myalgias. His mother, who remembered
removing a wood tick from her son's scalp 10 days earlier also developed a rash, fever,
and headache.
An ill appearing toddler with high fever and a diffuse red rash and edema suddenly
developed diffuse petechiae and ecchymoses. Laboratory studies showed a prolonged
bleeding time, thrombocytopenia, anemia, and neutropenia. After a prolonged course in
the pediatric intensive care unit, he recovered uneventfully with the exception of necrosis
of the tips of several toes.
Large (8 m body) 8-legged arachnid; black with brown leather pattern on body and legs

In the United States the most common vectors of Rickettsia rickettsii include
Dermacentor variabilis (American dog tick), Dermacentor andersoni (wood tick), and
Amblyomma americanum
Rocky Mounted Spotted
   − Rickettsia rickettsii gram neg intracellular
   − Clinical Presentation
       – HA, myalgias followed by rash on day3-5
       – Systemic-
   − Diagnosis
       – Indirect Fluorescent Antibody—6-10 days
         into illnes
       – PCR specific not sensitive
       – Bx—need expert for correct interpretation
   − Treatment
       – Doxycycline for all ages
       – Chloramphenicol
       – Duration 7-10 days
     – L. Akinbami and Tina L. Cheng
       Rocky Mountain Spotted Fever
       Pediatr. Rev., May 1998; 19: 171 - 172.
     – Theoklis Zaoutis and Joel D. Klein
       Enterovirus Infections
       Pediatr. Rev., Jun 1998; 19: 183 - 191.
              Theoklis Zaoutis and Joel D. Klein
              Enterovirus Infections
              Pediatr. Rev., Jun 1998; 19: 183 - 191.

     – Anjali Jain and Robert S. Daum
       Staphylococcal Infections in Children: Part
       Pediatr. Rev., Aug 1999; 20: 261 - 265.
     – Muhammad Waseem and Heidi Pinkert
       Visual Diagnosis: A Febrile Child Who Has
       "Red Eyes" and a Rash
       Pediatr. Rev., Jul 2003; 24: 245 - 248.
     – http://dermatlas.med.jhmi.edu/derm/

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