Rash and fever are some of the most common chief complaints presenting to the emergency department. The evaluation of rashes in the febrile pediatric patient includes a broad differential diagnosis and use of the history and physical examination to identify red flags, such as hemodynamic instability, erythroderma, desquamation, petechiae/purpura, mucous membrane involvement, and severe pain, that should increase suspicion for worrisome disease. This issue reviews characteristics of common rashes as well as rarer, potentially life-threatening rashes, to guide management and treatment and improve patient outcomes.
You arrive to a busy afternoon shift in the ED. Your first patient is a 1-year-old boy with rhinorrhea, congestion, cough, and 3 days of fever up to 39.4°C (103°F), measured rectally. His parents state that he has been playful at home and continues to eat and drink normally. They have been giving him acetaminophen and ibuprofen sporadically, but today he developed a generalized rash, and they became concerned. His vital signs are as follows: temperature, 38.7°C (101.7°F); heart rate, 135 beats/min; and blood pressure, 85/55 mm Hg. On examination, the rash is macular, erythematous, and blanching, but his eyes and mouth appear normal.
In the next room, there is a 3-year-old boy with a similar history who had mild rhinorrhea and a low-grade fever of 38.1°C (100.5°F) at home. His parents are concerned that he has been complaining of pain in his legs, on which they have noticed dark spots. He has continued to drink well, though he has been eating slightly less. His vitals signs are as follows: temperature, 37.5°C (99.5°F); heart rate, 120 beats/min; and blood pressure, 90/60 mm Hg. You observe some nonblanching spots on his lower extremities and buttocks, as well as mild edema and tenderness of his knees and ankle, but the boy is still able to bear weight with a mild limp.
Before you finish examining the boy, a nurse asks you to see another patient who she says does not look well. The patients is a 9-year-old girl with a history of ulcerative colitis who was sent from her pediatrician's office. She has had 4 days of sore throat and low-grade fever at home, and her parents assumed she had a cold. She tested positive for strep throat at her appointment today. Her vital signs are as follows: temperature, 38.5°C (101.3°F); heart rate, 126 beats/min; and blood pressure, 85/60 mm Hg. On examination, her skin appears diffusely erythematous as if she has a severe sunburn. These 3 patients all presented with dermatologic findings and fever. How do you determine which patients are truly ill, and which are not? Are there any red flags for recognizing rashes that could be life-threatening? Are there any key components to the history that are concerning? Do all of the patients need laboratory workup, or can you safely offer supportive care? Should any of these children be on isolation, either for their safety or for the safety of others?
According to a 2015 United States Centers for Disease Control and Prevention (CDC) report, the single most common chief complaint for children aged < 15 years was fever, and the fifth most common was skin rash.1 When paired, fever and rash may create a diagnostic dilemma for the emergency clinician. Although many relatively benign conditions present with these symptoms, some life-threatening disease states will also present as a rash in a febrile patient. Since the differential diagnosis is broad, most management decisions will be directed by key components of the history and physical examination, and any red flags. These findings should prompt consideration of diseases that would be severely detrimental to the child’s health if missed. Some rashes, such as varicella, measles, and rubella, may represent a public health concern. Diseases such as these have become slightly more prevalent in the United States, due to caregiver concerns regarding vaccinations. Rates of meningococcal disease have decreased; however, this disease does have high rates of morbidity and mortality.2
This issue of Pediatric Emergency Medicine Practice reviews various disease states, from benign to life-threatening, that can present as a fever with rash in a child. Workup, treatment, and disposition recommendations are provided based on key features of the history and physical examination.
A literature search was performed using PubMed. Search terms included fever, rash, viral exanthema, measles, scarlet fever, rubella, varicella, roseola, parvovirus, lyme disease, erythema migrans, Rocky Mountain spotted fever, acute rheumatic fever, erythema marginatum, Kawasaki disease, Henoch-Schönlein purpura, HSP and steroids, erythroderma, staphylococcal scalded skin syndrome, meningococcal disease, Neisseria meningitidis, purpura and fever, and toxic shock syndrome.
Multiple reviews and case reports were found, but, overall, evidence-based literature and original research was scarce. Information from the World Health Organization (WHO) and the CDC was also incorporated, as well as information from textbooks in infectious disease, emergency medicine, and pediatrics specialties.
The combination of rash and fever can be a chief complaint that many clinicians find challenging to manage, as there are a multitude of etiologies that can present with these symptoms; some are common diagnoses and others are “can’t miss” diagnoses. (See Table 1.) The can't miss diagnoses, when not identified and treated in a timely manner, can cause significant morbidity and mortality. Most well-recognized childhood exanthems are caused by viral etiologies. Many viruses can present with nonspecific exanthema; most commonly, a maculopapular/morbilliform pattern is seen.3 Table 2 describes some of the typical exanthema seen in pediatric patients. When attempting to determine the etiology, it is best to identify the characteristics of the rash first and then develop an appropriate differential diagnosis.
1. “This child had a sore throat with exudate and a rash. I thought it must be scarlet fever and gave him antibiotics.”
Prior to prescribing antibiotics, the characteristics of the rash, associated symptoms, history, and physical examination findings should be taken into account to develop the differential diagnosis. Many viruses can cause skin rash and exudative pharyngitis that would not benefit from antibiotics (eg, mononucleosis).
6. “This patient had a pretty nasty rash. I thought corticosteroids would help.”
Often corticosteroids are not indicated and may, in fact, worsen the underlying disease process. For many rashes, research does not support routine corticosteroid use, and corticosteroids can cause a bounce-back phenomena.
7. “This patient presented with symptoms of joint pain, rash, and fever, but I didn't think it could be acute rheumatic fever because the patient completed the full course of antibiotics for treatment of a streptococcal infection.”
ARF can still occur even in patients who received complete antibiotic treatment for streptococcal pharyngitis. If the presentation is suggestive of ARF, then appropriate testing should be performed. Diagnostic studies in patients for whom there is concern for ARF include a CBC with differential; inflammatory markers, including ESR and CRP; ASO titers; and electrocardiogram and echocardiogram.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Rhonda L. Philopena, MD; Erin M. Hanley, MD; Kayla Dueland-Kuhn, MD
Jeffrey R. Avner, MD, FAAP; Nicole Gerber, MD
January 2, 2020
February 1, 2023
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 0.5 Pharmacology CME credits.
Date of Original Release: January 1, 2019. Date of most recent review: December 15, 2019. Termination date: January 1, 2023.
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