Fever and rash in children. Haider Arishi MD Consultant, pediatrics and infectious diseases Director, infection control program

Transcription

1 Fever and rash in children Haider Arishi MD Consultant, pediatrics and infectious diseases Director, infection control program

2 objectives To understand importance of fever and rash. To discuss the clinical approach to DDX. To outline basic lab. work-up To address type of isolation of common diseases. To introduce fever without origin and its initial evaluation.

3 Definitions Rash skin eruption more than single lesion. Macule-circumscribed kin change without elevation. Papule-solid,raised lesion less than 1 cm. Nodule- same but more than 1cm. Vesicle- fluid-filled less than 1cm. Bulla- fluid-filled more than 1 cm. Petechia- small red/brown less than 1cm that does not blanche.

4 Importance of fever and rash Clues to serious underlying disease. Clues to a simple viral illness. Rash +/- fever could be sign of non-infectious DDX. Good history and physical examination Good DDX

5 History Age Season Travel history Geographic location, local and international. Exposures: insects, animals, and ill contacts Medications Immunizations Past childhood illnesses The immune status of child

6 History The rash Onset of rash and relation to fever. Distribution. Progression Associated symptoms. Cough Coryza Sore throat Conjunctivitis Diarrhea Joint pain or swelling others

7 Physical exam Hand hygiene+ surgical mask. First look- well or ill? Vitals - tachycardia / tachypnea - Low BP Rash type- macular, m- papular,viscular,petecheal, pustular, purpuric, necrotic. Distribution- including eyes, hands, feet and mucus membranes. Lymph nodes systemic - respiratory - abdomin- liver and splen enlargement. - CNS.

8 Differential diagnosis RASH infectious Non-infectious Viral Bacterial/toxinmediated Drugs Kawasaki HSP CTDs

9 Measles Maculopapular rash Starts in the head and neck area. Spreading centrifugally. fever, cough, coryza. Conjunctivitis. Dx clinical,confirm by IgM. Transmission-droplets

10 Chickenpox(varicella) Vesicular lesions on an erythematous base Appear in crops and are present in different stages from papules through vesicles to crusting. Diagnosis-clinical Transmission-airborne Prevention- vaccine

11 Rubella Rash resembles measles, Patient does not appear to be sick. Prominent postauricular, posterior cervical, and/or suboccipital adenopathy. Forscheimer spots, punctate soft palate macules. Spread by droplets,urine Dx: IgM Prevention: vaccine

12 Roseola infantum Human herpesvirus 6 or 7 infection High fever for 3-4 days Followed by seizures Generalized rash (trunk to extremities, face spared)

13 Hand-foot-mouth disease Enteroviruses Coxsackievirus A16 Enterovirus 71 Common,benign disease Spread by sliva,stool

14 Erythema infectiosum Erythema infectiosum (fifth disease) is due to human parvovirus B19. Children, unlike adults, often develop a characteristic rash with a "slapped cheeks".

15 Meningococcal disease Petecheal and purpuric rash. Rapid progression. Patient may die within hours of septic shock. Organisms can be seen under microscope from sampling skin rash. Penicillin must be started rapidly in emergency room.

16 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

17 Staphylococcal diseases Impetigo Scalded skin syndrome Toxic shock syndrome

18 Non-infectious causes(inflammatory) Drug eruptions, antibiotics Acute rheumatic fever Kawasaki syndrome HSP SLE

19 Lab investigations Complete blood count,diff. Blood cultures,csf if indicated. Serology if indicated Urinalysis Fluid from any lesions can be examined Unroof vesicles so that base of lesion can be swabbed Skin biopsy

20 FUO-definition An FUO in children has been defined as a daily rectal temperature greater than 38.3 C (101 F), lasting for at least 2 weeks, the cause of which has not been determined by simple diagnostic tests, including a complete history and thorough physical examination. Some experts would add that 1 of the 2 weeks of fever should be documented in the hospital.

21 Step-wise approach Careful documentation of fever is necessary before diagnosing FUO. The physician should instruct the parents in the technique of taking a rectal temperature. Day of fever as a 24-hour period in which a temperature greater than 38.3 C (101 F) occurs at least once. Serial careful exams in hospital. Start with,basic, noninvasive investigations.

22 Pseudo fever Absence of documented, persistent fever Lack of objective, abnormal physical findings History of significant or near-fatal illness Parental fear of malignant or crippling disease Frequent environmental exposure to illness Absence of persistent weight loss Normal erythrocyte sedimentation rate and platelet count Many missed school days because of subjective morning complaints Discordance of fever and pulse rate Medical or paramedical family background One or more of mild self-limited diseases, behavioral problems, parents who have misconceptions concerning health and disease, or families under stress

23 FUO-DDX I. Infectious causes Comprising between 40% and 60%. Most infections that exhibit themselves as an FUO are an atypical or incomplete manifestation of a common disease. Viral, bacterial, parasitic and fungal. EBV, osteomyelitis, brucellosis, hidden abscesses, TB, HIV are common diagnoses.

24 FUO-DDx II. Non-infectious Autoimmune (7-20 %) CIJA (CJRA), SLE Malignancy ( 2-6 %)- lymphoma, leukemia,neuroblastoma, others. No obvious cause ( 20 % +)- well-looking children, fever resolves at end. Drug fever Periodic Fever Syndromes Cyclic neutropenia Familial Mediterranean fever Hyperimmunoglobulinemia D and periodic fever syndrome (HIDS) Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenopathy (PFAPA)

25 FUO-evaluation History Information regarding travel, patient residence. Animal exposure, exposure to other persons who have febrile illnesses previous illness, hospitalizations, medications, family history of disease. precise course of the exhibiting symptoms Meticulous documentation of dates is especially important. Family record on a calendar, both the daily time and height of the fever along with associated symptoms.

26 FUO-evaluation Physical examination Vital signs Growth parameters + plotting. Skin rash lymphadenopathy. ENT Teeth Heart murmurs Abdomen tenderness, masses, liver and spleen, perennial M-skeletal in details.

27 FUO-lab evaluation If the history and physical examination disclose no specific findings and growth is normal-only simple diagnostic tests are indicated. CBC,diff Cultures- blood, urine,throat. ESR,CRP, Albumin-globulin ratio. Serology : EBV, hepatitis A,B,Toxo. US abdomen Not routine tests (based on individual patient assessment) - bone scan - CT,MRI - bone marrow aspiration - HIV screening.

28 FUO-conclusion Infections are most common followed by autoimmune diseases. If the ESR, CRP, and the albumin-globulin ratio are normal and no signs and symptoms are present that are specific to a particular disease, little can be gained from additional tests. Observation and periodic evaluation are the only measures that are required while remaining alert for the occurrence of new symptoms or signs that might lead to specific direction. parents and patient will be anxious about an undiagnosable problem Physician must be ready to provide all family members with a clear explanation of the evaluative process, any normal results, and reassurance. Referrals /consultation may be necessary for additional assistance in determining a diagnosis.

29 Thank you