Approach to a the Child with a Fever and Rash

General Presentation
Children frequently present at the physicians 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
1. Measles:

Blanching erythematous maculopapular rash

Begins in head and neck 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 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 desquamation

Circumoral pallor and strawberry tongue

7. Non-polio enteroviruses (coxsackievirus, echovirus)

Cause variety of different rashes

Should be included in differential

Inflammatory causes
1. 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

References
1. Lopez FA, Sanders CV. Fever and rash in the immunocompetent patient. In: UpToDate,
Basow, DS (Ed), UpToDate, Waltham, MA, 2011
2. Barinaga JL, Skolnik PR. Clinical presentation and diagnosis of measles. In: UpToDate,
Basow, DS (Ed), UpToDate, Waltham, MA, 2011
3. Albrecht MA. Clinical features of varicella-zoster virus infection: chickenpox. In:
UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011
4. Jordan JA. Clinical manifestations and pathogenesis of human parvovirus B19
infection. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2011