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.
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).
2. “The patient did not have strep throat recently, so it can’t be acute rheumatic fever.”
Often, children have an episode of pharyngitis and do not have a rapid strep test performed to make the diagnosis of “strep throat.” Additionally, the symptoms of ARF appear after a 2- to 3-week latent period following the streptococcal pharyngitis, so prior infection may not be evident at the time of presentation.
3. “The patient has had 5 days of fever and now has a rash; this is probably just a viral exanthem.”
In the setting of 5 days of fever, Kawasaki disease should be considered, especially in infants who may not have the classic presentation of fever ≥ 5 days and at least 4 out of the 5 following clinical features: (1) conjunctival injection, (2) mucous membrane changes (bright red, cracked lips, strawberry tongue), (3) changes in peripheral extremities (usually a later finding), (4) polymorphous rash, and (5) cervical lymphadenopathy.
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.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 0.5 Pharmacology CME credits, subject to your state and institutional approval.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Philopena, Dr. Hanley, Dr. Dueland-Kuhn, Dr. Avner, Dr. Gerber, Dr. Mishler, Dr. Claudius, Dr. Horeczko, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of this article. (2) Mail or fax the CME Answer And Evaluation Form with your June and December issues to Pediatric Emergency Medicine Practice.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.