FEVER WITH RASH IN CHILDREN

• PRESENT BY :
– DR.GARIMA SHARMA
– DR.ASHIT SHETH
– DR.AMARJIT GUPTA

• MODERATORS :
– DR.ALOK C. BHARDWAJ
– DR.PRABHAT KUMAR
 FEVER WITH RASH IN CHILDREN
INTRODUCTION :

 Fever with rash is one of the leading complaints

among children.
 Most causes are viral in origin and benign in
nature.
 A few life-threatening cause of rashes needs to be
recognized.
 COMMON SKIN LESION
MACULE

• Macule is a circumscribed,
flat lesion of skin, which is
visible because of a change
in skin color .
• Not felt, as no change in
skin texture
 PAPULES
• Small, solid, elevated
lesion
• <0.5 cm in diameter.
• A major portion of the
papule projects above
the skin.
Papules can be due to:
• Hyperplasia of cellular
components of epidermis
or dermis.
 BLISTERS
Blisters are fluid filled,
circumscribed, elevated
lesions, formed due to
split in the skin.

A. Vesicles <0.5 cm in
diameter.
B. Bullae. >0.5 cm in
diameter.
 PUSTULES & ABSCESS
• Pustule:
– PUS-FILLED VESICLE.
A. follicular (conical) or
B. extrafollicular.
• Abscess:
– PUS-FILLED NODULE,
having a thick wall .
– usually deep seated with
only a part of it visible
on the surface
 PETECHIAE/PURPURA /ECCHYMOSIS
• Erythematous macules
due to extravasation of
RBCs into dermis.
• Non-blanchable.
A. PETECHIAE 1-3mm
B. PURPURA >3mm
C. ECCHYMOSIS >1-2cm
 URTICARIA
• Heterogeneous group of
disorders characterized
by itchy wheals, which
develop due to
evanescent edema of
dermis.
 ERYTHEMA NODOSUM
• Tender red nodules,
due to exudation of
blood and serum
 LETS DISCUSS ABOUT
COMMON CASES WE
ENCOUNTER
DURING OUR DAILY PRACTICE
 RASHES :
TIME OF APPEARANCE AFTER FEVER ONSET
• Day 1 - Varicella
• Day 2 - Scarlet fever
• Day 3 - Chickenpox
• Day 4 - Measles
• Day 5 - Typhus and Rickettsia
• Day 6 - Dengue
• Day 7- Enteric
Very Sick Child Must Take Double Eggs
 MEASLES
• Highly contagious viral illness
• The causative agent, measles virus (MV), is a member of the
family Paramyxoviridae .
• Rash appear 2–4 days after onset of fever; it consists of an
erythematous, maculopapular, blanching rash, which
classically begins on the face and spreads cephalocaudally
and centrifugally to involve the neck, upper trunk, lower
trunk, and extremities.
• Associated symptoms fever , cough, coryza, conjunctivitis
• Diagnosis: Measles IgM, RT-PCR
• Treatment – Supportive, Vitamin A supplements
Dew drop on a
rose petal
 CHICKENPOX
• Cause by Varicella-zoster virus .
• Rash Initially as small red papules that rapidly
progress to oval, non umblicated “ teardrop” vesicles
on erythematous base
• Lesion present in different stages papules, vesicles,
crusting.
• New crops appear for 3 to 4 day beginning on the
trunk followed by the head , the face and less
commonly the extremities.
• PCR is the diagnostic method of choice
• Treatment supportive
Forschheimer spots
 RUBELLA
• Rash resembles measles but patient is not ill
looking
• Forschhemier spots: small red spots (petechiae)
on soft palate in 20% of rubella patients.
• Prominent post auricular, posterior cervical
lymphadenopathy
• IgM antibodies diagnostic for congenital rubella
syndrome
• Treatment supportive
ROSEOLA INFANTUM OR EXANTHEMA
SUBITUM

• Human herpesvirus 6 or 7 infection

• Fever. Roseola often starts with a high fever often
higher than 103 F (39.4 C). It starts suddenly and
lasts 3 to 5 days.
• Rash. After the fever goes away, a rash often
appears. A roseola rash is many small spots or
patches. These spots tend to be flat.
• Some children also may have a sore throat, runny
nose or cough ,may also develop swollen lymph
nodes in the neck.
 HAND-FOOT-AND-MOUTH DISEASE

• It is a mild, contagious viral infection common in young children.

• most commonly caused by a coxsackievirus A 16 and enterovirus 71.
• Fever.
• A rash on the palms, soles and sometimes the buttocks. The rash is
not itchy, but sometimes it has blisters. Depending on skin tone,
the rash may appear red, white, gray, or only show as tiny bumps
• Sore throat.
• Feeling sick.
• Painful, blister-like lesions on the tongue, gums and inside of the
cheeks.
• Loss of appetite.
• Treatment supportive
 Strawberry tongue
Pastia’sLines

Sandpaper Rash
 SCARLET FEVER
• Exotoxin-mediated diffuse erythematous rash
• Rash begins on upper chest/neck 1-2 days after the onset
of infection and spreads to trunk and extremities
• Diffuse erythema that blanches- sandpaper texture of
skin
• Pinpoint areas of deeper red scattered petechiae
non-blanching -Pastia's lines
• Circumoral pallor and strawberry tongue.
• Diagnosis group A streptococcus is present in throat swab.
• Treatment – rehydration , antibiotics
 DENGUE FEVER
• Dengue fever is a tropical
mosquito born disease that cause
flu-like symptoms, rash and joint
pain.
• High grade fever
• A flat, red rash may appear over
most of the body 2 to 5 days
after the fever starts.
• Backaches and headaches
• Bleeding present
• Diagnosis by isolation of virus,
serology test & PCR
• Treatment supportive
Rose spots
 TYPHOID/ENTERIC FEVER
• Cause by salmonella
• Common in countries with poor sanitation
• Present fever that rise gradually to 102F to 104 F
• Temporary rash 2 to 4 mm in diameter with raised
pink blanching spots on the stomach and chest
• Headache and sore throat
• Stomach pain constipation and diarrhea
• Diagnosis blood and stool culture and serum test
• Treatment rehydration and antibiotics
Eschar
 TYPHUS
• Caused by rickettsial bacteria and transmitted by arthropods
• High fever, headache
• Rash The rash of murine typhus presents as fine erythematous
papules on the abdomen, which spreads centripetally to the
trunk and extremities but often spares the face, palms, and
soles.
• Eschar is a necrotic lesion of the skin at the site of a chigger mite
bite.
• Confusion and stupor
• Hypotension
• Eye sensitive to bright lights
• Diagnosis skin biopsy of rash, western blot and
immunofluorescence test
• Treatment Doxycycline
 KAWASAKI DISEASE
• Usually in kids <4 years old
• Fever >5 days
• B/L conjunctival infection
• Strawberry tongue
• Erythema in palm or sole
• Edema of hand or feet
• Rash- Rash in KD appears during the first few
days of onset of fever.
• It is polymorphous, varying from macular to
maculopapular or morbilliform, however, it is
never vesicular. It most commonly begins on
the trunk and spreads over the next few days
to involve the extremities
• Cervical lymphadenopathy
• Generalized or periungual desquamation
• Treatment IVIG and Asprin
 ERYTHEMA MARGINATUM
• Characteristic rash of
rheumatic fever (RF)
• Erythematous,
serpiginous,
and macular lesions with
pale centers
• Nonpruritic
• Involves trunk and
extremities,
spares the face
 INFECTIOUS MONONUCLEOSIS
• Cause by Epastin-barr virus
• Has particular tropism for B
lymphocytes and epithelial cells.
• Rash in IM is known to appear
after exposure to antimicrobials
and maculopapular.
• Fever , malaise
• Tonsillopharygitis- often sever,
limiting oral ingestion of fluids.
• Lymphadenopathy – prominent
cervical lymph node
• Splenomegaly , hepatomegaly
 SYSTEMIC LUPUS ERYTHROMATOSIS
• Serositis (pleuritis or pericarditis)
• Malar rash
• Discoid rash
• 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)
 STEVENS-JOHNSON SYNDROME (SJS) AND
TOXIC EPIDERMAL NECROLYSIS (TEN)
• Stevens-Johnson syndrome and toxic epidermal necrolysis are
commonly caused by drugs or infections.
• Typical symptoms for both diseases include peeling skin, fever,
body aches, a flat red rash, and blisters and sores on the mucous
membrane
Stevens-Johnson syndrome causes only small areas of peeling skin
(affecting less than 10% of the body).

Toxic epidermal necrolysis causes large areas of peeling skin (affecting

over 30% of the body).

overlap of Stevens-Johnson syndrome Involvement of 15 to 30% of body surface

and toxic epidermal necrolysis. area is considered
 HENOCH-SCHÖNLEIN PURPURA
• IgA vasculitis (IgA), formerly known
as Henoch-Schönlein purpura (HSP)
• immune complex-mediated small
vessel vasculitis of childhood.
• It is the most common pediatric
vasculitis affecting children of all age
groups.
• Rash - Palpable purpura, petechiae
and ecchymoses May be preceded
by urticarial, erythematous,
maculopapular or bullous skin
lesions.
 LEUKEMIA
• Skin symptoms that can
occur with leukemia
include:
• easy bruising
• petechiae or purpura
• mouth sores
• more frequent skin
infections
AN ALGORITHM APPROACH TO
PEDIATRIC DIAGNOSIS

WHAT’S LATEST UPDATE IN THE IAP

GUIDELINES…
LIFE-THREATENING CAUSES OF FEVER WITH
RASH
 RED FLAG SIGNS
• Petechial/purpuric rash specially < 2 years of
age 
• With meningeal signs 
• Associated with weight loss, anorexia 
• Associated with unstable vitals 
• Toxic appearance
APPROACH BASED ON ASSOCIATED
CLINICAL FEATURES
APPROACH BASED ON RASH MORPHOLOGY
 DRUG RASH
• Commonly maculopapular eruptions 
• Appear within 7–14 days of start of the treatment 
• The commonly implicated drugs are beta lactams,
sulfonamides, nonsteroidal anti-inflammatory drugs
(NSAIDs), and anticonvulsants. 
• Diagnosed by absence of prodromal symptoms, presence
of severe itching, absence of high-grade fevers commonly,
temporal relation to drug intake, confluence of rash on
dependent areas 
• Reappearance of rash on drug provocation confirms
diagnosis.