General Presentation Children frequently present at the physician’s office or emergency room with a fever and rash. Although the differential diagnosis is very broad, adequate history and physical examination can help the clinician narrow down a list of more probable etiologies. It is important for physicians to be diligent, as the differential diagnosis can include contagious infections or life-threatening diseases. Even though there is a strong link between the presentation of fever and rash and infectious disease, it is important to keep in mind that other non-infectious diseases can also have similar presentations (e.g. drug reactions, cutaneous lupus erythematosus, inflammatory bowel disease). Presentation Features of the rash: – Characteristic of lesions – Distribution and progression – Timing of onset in relation to fever – Morphological changes (e.g. papules to vesicles) Common skin lesions: – Macule: nonpalpable, circumscribed, flat lesion (<1 cm in diameter) – Papule: palpable , elevated lesion (<1 cm in diameter) – Maculopapular: combination of macular and popular lesions – Purpura: non-blanching papules or macules due to extravasation of RBCs – Vesicle: fluid-filled, elevated skin lesion (<1 cm in diameter) – Bulla: fluid-filled, elevated skin lesion (>1 cm in diameter) – Pustule: pus-containing vesicle – Ulcer: depressed skin lesion with missing epidermis and upper layer of dermis Questions to Ask It is important to consider the following: – Age of patient – Season – Travel history – Geographic location – Exposures to insects, animals, other people who are ill – Medications – Immunization history – Other medical conditions – Immune status of patient – Was there a prodrome? (early symptoms that might indicate the start of disease) – When did the rash start? – Where did the rash start? – Where has the rash spread to? – Has there been any change in the rash (appearance, sensation, etc.) – What has been used to treat the rash? – Review of systems to rule out inflammatory bowel disease (diarrhea, weight loss, poor appetite, arthritis, etc.) – Review of systems for SLE (photosensitivity, malar or discoid rash, cytopenias, renal disease, etc.) Differential Diagnosis Infectious causes Measles: – Blanching erythematous maculopapular rash – Begins in head and neck à spreads centrifugally to trunk and exrtremities – Associated symptoms: fever, cough, coryza and conjunctivitis 2. Chickenpox: – Vesicular lesions on erythematous base – Lesions appear in crops – “dew drops on rose petals” appearance – Lesions are present in different stages: papules, vesicles, crusting 3. Rubella: – Rash resembles measles, but patient is not ill looking – Prominent postauricular, posterior cervical +/- suboccipital adenopathy – Forschemier spots: small, red spots (petechiae) on soft palate in 20% of rubella patients 4. Erythema infectiosum (fifth disease) – human parvovirus B19 – Characteristic rash that resembles “slapped cheeks” 5. Roseola infantum or exanthema subitum – Human herpesvirus 6 or 7 infection – High fever for 3-4 days – Followed by seizures – Generalized rash (trunk to extremities, face spared) 6. Scarlet fever – Exotoxin-mediated diffuse erythematous rash – Pharyngitis due to group A streptococcus – Coarse, sandpaper-like, erythematous, blanching rash à desquamation – Circumoral pallor and strawberry tongue 7. Non-polio enteroviruses (coxsackievirus, echovirus) – Cause variety of different rashes – Should be included in differential Inflammatory causes Acute rheumatic fever – Potential sequela of group A streptococcal pharyngitis – Erythema marginatum – transient macular lesions with central clearing usually found on extensor surfaces of proximal extremities and trunk – Subcutaneous nodules over bony prominences 2. Kawasaki Vasculitis – Usually in kids <4 years old – Fever >5 days – Bilateral conjunctival injection, injected or fissured lips – Injected pharynx or “strawberry tongue” – Erythema of palms or soles – Edema of hands or feet – Generalized or periungual desquamation – Rash – Cervical lymphadenopath – Acute rheumatic fever 3. systemic lupus Erythromatosis SOAPBRAINMD: – Serositis (pleuritis or pericarditis) – Oral (Ulcers) – Arthritis (Non-erosive, any joint, polyarticular) – Photosensitive rash – Blood dyscrasia (anemia, leukopenia, lymphopenia or thrombocytopenia) – Renal Nephritis – ANA – Immunoreactive (anti-Ds DNA, Anti-Rho, Anti-Sm, Anti-La, antiphospholipid) – Neurological (Sz, Chorea, Psychosis) – Malar rash – Discoid rash 4. Inflammatory Bowel Disease Associates with two rashes characteristically: – Erythema Nodosum – Pyderma Gangrenosum Procedure for Investigation Physical Examination – Vital signs – General appearance – energy level, does the child look sick? – Lymph node, mucous membranes, conjunctivae and genitalia assessment – Meningeal signs – Neurologic evaluation – Liver and spleen palpation – Joint examination – Skin examination Laboratory Tests – Complete blood count – Urinalysis – Blood cultures – depending on history of possible exposures – Serologies – if indicated – Fluid from any lesions can be examined – Unroof vesicles so that base of lesion can be swabbed – Skin biopsy Source
