Fever With Rash 1

Fever and rash in children
Dr. A. Gervaix, 2005

Diffential diagnosis of fever and rash
Viruses Bacteria Other
Maculo/papular rash Measles, rubella, HHV-6 Rickettsia

GABHS (scarlet fever)…
EBV, HBV, HIV, enterovirus..
Salmonella, Lyme,
Mycoplasma pneumoniae
Vesicular, bullous
VZV, HSV, Echovirus
Impetigo (GAS) …
Coxsackievirus A, B
Petechial
CMV, enterovirus, EBV Sepsis (N.men, S.pneu,Hib) Rickettsia
Hemorrhagic fever, VZV Rat bite fever (S. minus)…
Diffuse erythroderma
Dengue GABHS (scarlet fever), C.

Urticarial rash TSS albicans
EBV, HBV, HIV, M. pneumoniae, GAS

Enterovirus…
Essential elements of the history in the clinical assessment of fever and rash
• Demographic data • Features of rash

Age Temporal association (onset relative to fever)
Gender Progression and evolution
Ethnicity Location and distribution
Season Pain or pruritus
Geographic area
• Prior health status
•Exposures Medical and surgical history
Ill contacts (home, day care…) Growth and development
Travel Recurrent infectious illnesses
Pets, insects
Medications and drugs
Immunization
•Family history
• Associated symptoms
Focal (suggesting organ-specific illness)
Systemic (multisystem illness)
Essential elements of the physical examination in the clinical assessment

of fever and rash
• Degree of toxicity
• Characteristics of rash
Macular
Papular
Maculo-papular
Petechiae or purpura
Diffuse/localized erythroderma
Vesicles, pustules, bullae
Nodules
• Associated enanthem
Buccal and genital mucosa
Palate
Pharynx and tonsils
• Associated findings
Arthritis, ocular, GI, cardiac…
Clinical case #1
History:
9 mo old girl, good general health condition
Progressive fever for 3 days (max. 39.50C)
Coryza, exudative conjontivitis,
severe cough and irritability
No diarrhea, no vomiting
No recent travel, no pets
Attends day care 2d/w
Confluent maculo-papular rash all over the body

Measles
Acute viral infection
Human being is the only reservoir
Caused by a paramyxovirus
Very contagious (reach 90% of

susceptible contacts within a family.
Respiratory route)
Measles
Clinical features
Incubation period: 10-12 days
Prodroms: 3-5 days

coryza,
conjunctivitis,
cough, fever
Koplick’s spots
Rash
Measles
Koplik’s spots
Pathognomonic of measles
Measles
Measles
• The rash starts behind the ears and on the forehead at the hair line
• The spread of the rash is centrifugal (head to legs)

Measles
Diagnosis:
Clinical
Serology
Viral culture
PCR
Measles
Complications (more severe in adults)
• Acute otitis media (10-15%)
• Interstitial pneumonia (50-75% pathological chest RX)
• Myocarditis and pericarditis
• Encephalitis (1/1000 cases) 7-10 days after rash

(1/3 died, 1/3 sequeallae, 1/3 full recovery)
• Subacute sclerosis panencephalitis (SSPE)

(0.2-2 /100’000 infections, mean incubation 7 y.)
Case fatality rate is 100% after 6 to 9 months
Measles
Treatment
• No specific antiviral treatment
• Vaccination within 72h after contact
• Immunoglobulins within 6 days after contact in

immunocompromised and < 1 y old children
Measles is a preventable disease !!!

Live attenuated vaccine (combined with rubella and mumps): 2 doses
Reported cases of measles in Maryland,

Important notice …
Eradication of measles can be obtained if >95% of the population is immune
Measles is endemic if 15-20% of the population is susceptible
Epidemics can occur if > 25% of the population is susceptible
… vaccinate your children
« No evidence for measles, mumps, and rubella vaccine-associated

inflammatory bowel disease or autism in a 14-y prospective study »
Peltola et al. Lancet 1998
without fear
Clinical case #2
History: 7 y. old boy, good general health condition

Sudden onset of sore throat since 24h and
fever at 390C. Abdominal pain and
1 episode of vomiting
No conjuntivitis,
No rhinitis,
No hoarseness
No cough
Attends primary school, no recent travel
Maculo-papular rash
Scarlet fever - Scarlatina
Scarlatina is caused by erythrogenic
exotoxin producing strains of
Group A ß-hemolytic Streptococci
Common among school-age children

(very unsual in < 2 y old)
5-10% of healthy carriers
Transmission by direct contact or respiratory

droplets
Incubation: 2 to 5 days
Untreated cases remain infectious for a

prolonged period, unlikely after 24h of
appropriate antibiotic therapy
Clinical features
Abrupt onset
Fever
Sore throat
Abdominal pain
Variable pharyngitis
Tender lymphadenopathy
Diffuse erythroderma (red sandpaper)
• The rash develops often within 12h (always within

2d) after the onset of symptoms
• Generalized confluent rash on the cheeks and

forehead but with circumoral palor
• Spreads onto the neck and trunk, sparser on the

limbs
• Usually involves palms and soles of feet


Thick, white layer through
which red papillae protrude
(white strawberry tongue)
Peeling after several days

(red strawberry tongue)
Pintpoint petechiae in the flexures produce a linear

purpuric pattern (pathognomonic)
= Pastia’s lines
After a week, the rash typically

starts to desquamate,
particularly on the hands and
feet
Complications of GAS infection
Local: Otitis media

Pharyngeal abcess
Adenitis
Invasive: Sepsis
Non suppurative: Glomerulonephritis

rheumatic fever
erythema nodosum
(No more likely to follow scarlet fever than other group A streptococcal infection)
Diagnosis: Clinical
Rapid strep test
Culture
ASLO
Treatment: Antibiotics (penicillin)

Clinical case #3
History:
6 y. old girl, good general health condition
headache, abdominal discomfort.
Temp. 38.30C
Goes to school
after 3 days bright erythematous facial exanthem

« Slapped cheek disease », fifth disease, erythema infectiosum
Caused by Parvovirus B19
Discovered in 1975
Causes spring epidemics in children

4-10y (attack rate 40%)
Often asymptomatic
Seroprevalence of 50% at age 15

Seroconversion of 1.5%/y in childbearing aged women
Erythema infectiosum
Incubation of 4-14 days
Clinical features
Stage I
Mild prodromal illness
low grade fever
headache
GI symptoms
Stage II (+3-7 days)

Erythematous facial exanthem
(slapped cheeks )
Stage III (+1-4 days)

Lacy maculo-papular exanthem
on the trunk and extremities.
May be pruritic, evanescent,
recurring over 1-3 weeks
Arthropathy (adults >> children,
female >> male)
Erythema infectiosum
Children are infectious

during the prodromal stage
and do not shed virus at
the time of the rash
anymore
Control of epidemics very

difficult
Complications of parvovirus B19 infection
• Erythrocyte aplasia
(by direct infection of the red cell precursors)
• Intrauterine infection
(hydrops fetalis (5% of infected fœtus),
rash, hepatomegaly, cardiomegaly and anemia)
Parvovirus B19
Diagnosis
Clinical
Serology (arthritis,
red cell aplasia..)
Treatment
No specific treatment
Clinical case #4
History: 6 month old boy,

No past medical history
No prodromes
Fever 400C of sudden onset
Febrile convulsion
3 days later the fever abates and widespread macular rash

Roseola infantum,
exanthem subitum,
Caused by Human herpes virus type 6 (HHV-6B) « sixth disease »
in rare cases by HHV-7
• Discovered in 1988
• >95 % of children are affected
• Almost all cases between 4 mo and 2 years
• Sporadic illness (rare outbreaks)
• No seasonal distribution
• Reactivation possible (immunosuppressed persons)

Clinical manifestations ROSEOLA
• Often asymptomatic
• Few prodromes (rhinorrhea, diarrhea)
• Sudden onset of fever (39-400C)

lasting 3-5 days
• Rose-coloured macular rash, rarely confluent,

present for few hours up to 2days
Affects the neck and trunk extending to the
face and proximal extremities
• No pruritus, no desquamation
Associated with febrile convulsion

ROSEOLA
Diagnosis
• Clinical
• Serology
• PCR
Treatment
• Symptomatic (antipyretics)
Clinical case #5
History: 5 y old boy, no special past medical history

Low grade fever (38.30C) for 48 h
Attends school
No travel history
No pets
Vesicular rash on the trunk and face

Varicella /chickenpox
Caused by varicella/zoster virus (VZV,

herpes virus family)
Most common exanthematous disease

of childhood
Humans are the only reservoir
Affects 90% of children between 1 to

14 years
Highly contagious (>90% in household

contacts)
Contagiosity: 2 days before to 5 days

after the rash
Occurs in late winter early spring
Less common in tropical climates
Incubation period 14 days (10-21)
Replication at the site of infection,

primary viremia which establishes
replication in the reticulo-endothelial
system. A secondary viremia occurs
after about a week with disseminates
to the skin
Establishment of latency in sensory

ganglia
reactivates years later to cause zoster

Clinical manifestations
Prodromes with 1-2 days of
low grade fever
• Erythematous papules
• Vesicules
• Pustules
• Crust
Spread from the trunk to the

face, neck and extremities
Pruritus +++
Mucous membranes can be

involved
The hall mark of the varicella rash is the simultaneous

presence of lesions of different stages
Diagnosis
• Clinical
• Serology
• Immunofluorescence
• Culture
• PCR
Complications
• Congénital infection (2%, 18-22 w of gestation)

Small size, cutaneous scarring, limb hyplasia, microcephaly,
cortical atrophy, chorioretinitis, cataracts ….
• Perinatal infection
5 days before to 2 days after birth

(high mortality without treatment 30%)
Complications #2
Increase with age
•Pneumonia
Rare in children, high mortality in immunocompromised host)
• Cerebellar ataxia (1/4000 in <15 y)

Develops 7 to 10 days into the disease,
excellent prognosis
• Transvere myelitis, Guillain-Barre sy.
• Hemorrhagic varicella
Thrombocytopenia
Complications #3
• Superinfections
locally with S. aureus or GABHS

cellulitis
systemic with GABHS

sepsis, necrotizing fasceitis
Strep. TSS
• Reye syndrome
Persistant vomiting, decreasing mental status, liver failure.
Associated with salicylate-containing products
Avoid aspirin in varicella !!!
Treatment
Secondary prevention
Must be administered by 96h after exposure (or better if < 72h)
Primary and secondary prevention by a vaccine

Clinical case #6
History: 20 mo old boy
High fever (39.50C) for 5 days

remittent with several spikes each day
Irritable
No cough
Physical examination
Bad general condition
Polymorphous rash
conjunctival injection
fissured lips
cervical lymphadenopathy (>1.5 cm)
No travel history
No pets
Vaccination: OK for the age
KAWASAKI disease
First described in 1967
Incidence: 67 cases /100’000 in Japan

5.6 cases/100’000 in the USA
85% in children < 5 years (peak 18-24 mo)
Rarely occurs in adolescent, adults or

children < 6 mo .
M/F ratio 1.4:1
Occurs often in late winter and spring
Etiology: UKNOWN
Pathophysiology: « Superantigen theory »

causing an intense vasculitis
KAWASAKI disease
Clinical presentation
92%
65%
KAWASAKI disease
75%
KAWASAKI disease
77%
90%
50-75%
KAWASAKI disease
Associated findings
Aseptic meningitis (25%)

Arthritis and arthralgia (20-40%)
Laboratory
Diarrhoea
Hydrops of the gallbladder High ESR and CRP
Sterile pyuria
High platelet count (second week)

Differential diagnosis
Measles, scarlet fever

TSS, Steven-Johnson sy,
Juvenile rheumatoid arthritis…
KAWASAKI disease
Complications
Coronary aneuvrysm
Prognosis
75% no sequelae, 25% coronary abnormality (without treatment),

1-2% mortality in the acute phase
KAWASAKI disease
Treatment
Immunoglobulins 2g/kg body weight
Aspirin 80-100 mg/kg/day during

the acute phase
then 3-5 mg/kg/day for months when

fever subsides
Have you questions about
FEVER & RASH ?

Fever With Rash 1

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Fever With Rash 1

Uploaded by

Copyright:

Available Formats

Fever and rash in children

Dr. A. Gervaix, 2005

Diffential diagnosis of fever and rash

Viruses Bacteria Other

Maculo/papular rash Measles, rubella, HHV-6 Rickettsia

Dengue GABHS (scarlet fever), C.

EBV, HBV, HIV, M. pneumoniae, GAS

• Demographic data • Features of rash

Essential elements of the physical examination in the clinical assessment

Confluent maculo-papular rash all over the body

Acute viral infection

Human being is the only reservoir

Very contagious (reach 90% of

Incubation period: 10-12 days

Prodroms: 3-5 days

• The spread of the rash is centrifugal (head to legs)

Complications (more severe in adults)

• Acute otitis media (10-15%)

• Interstitial pneumonia (50-75% pathological chest RX)

• Myocarditis and pericarditis

• Encephalitis (1/1000 cases) 7-10 days after rash

• Subacute sclerosis panencephalitis (SSPE)

• No specific antiviral treatment

• Vaccination within 72h after contact

• Immunoglobulins within 6 days after contact in

Measles is a preventable disease !!!

Reported cases of measles in Maryland,

Eradication of measles can be obtained if >95% of the population is immune

Measles is endemic if 15-20% of the population is susceptible

Epidemics can occur if > 25% of the population is susceptible

… vaccinate your children

« No evidence for measles, mumps, and rubella vaccine-associated

Peltola et al. Lancet 1998

History: 7 y. old boy, good general health condition

Attends primary school, no recent travel

Group A ß-hemolytic Streptococci

Common among school-age children

5-10% of healthy carriers

Transmission by direct contact or respiratory

Untreated cases remain infectious for a

Scarlet fever - Scarlatina

Diffuse erythroderma (red sandpaper)

• The rash develops often within 12h (always within

• Generalized confluent rash on the cheeks and

• Spreads onto the neck and trunk, sparser on the

• Usually involves palms and soles of feet

Scarlet fever - Scarlatina

Peeling after several days

Pintpoint petechiae in the flexures produce a linear

Scarlet fever - Scarlatina

After a week, the rash typically

Scarlet fever - Scarlatina

Complications of GAS infection

Local: Otitis media

Non suppurative: Glomerulonephritis

Scarlet fever - Scarlatina

Treatment: Antibiotics (penicillin)

after 3 days bright erythematous facial exanthem

« Slapped cheek disease », fifth disease, erythema infectiosum

Caused by Parvovirus B19

Causes spring epidemics in children

Seroprevalence of 50% at age 15