Approach to a child with fever and rash

• This condition can be caused by drug reaction, infection or
an allergic reaction.
• Different agents can cause rash that look the same
• Often symptoms in addition to rash helps in making the
diagnosis.
• Most rashes caused by viruses do not harm child but some
are life threatening.

• 10% of all febrile children have dermatological problem.
• Morphology of skin lesion can contribute to diagnosis.
• In drug reactions we see more than one type of morphology at a
given point of time.
• At times lesion goes through stages, in such cases presenting
lesion along with relevant evidence from history on evolution
helps in diagnosis.

• Allergy:
Urticaria
Drug rash
Allergic vasculitis
• Infection:
Measles
Rubella
Varicella
Dengue
Scarlet fever
Typhoid
meningococcemia

• Other illnesses:
Kawasaki disease
SLE
Erythema multiforme
Toxic epidermal necrolysis(TEN)
Staphylococcal scalded skin syndrome(SSSS)
Erythema marginatum
Erythema infectiosum
Dermatomyositis
Hand foot and mouth disease (HFMD)

• History taking
• Cinical examination.
• Relevant laboratory work up

• WITH REGARD TO FEVER:
• Onset
• Duration
• Diurnal variation.
• Other symptoms.
• WITH REGARD TO RASH:
• Distribution of rash
• Morphology or pattern of rash.
• Evolution
• Prodrome, if any

• Grade of fever.
• Pattern of fever.
• Type of skin lesion.
• Distribution
• Site of first appearance.
• Evolution
• Tenderness
• Mucosal involvement
• Involvement of palms, soles.hair.nails.
• Other systems.

MACULE:
Circumscribed area of change in skin color without any
change in consistency.
<1cm diameter
PAPULES AND NODULES:
Solid lesion <0.5cm in diameter; major part of it
projecting above the skin is a papule.
Solid lesion >0.5cm but <1cm in diameter with major
part in the skin is a nodule.

PLAQUE:
Area of altered skin consistency, surface area of
which is greater than depth.
WHEAL:
Characteristic lesion in urticaria.
Pale or erythematous raised lesion which disappears
within 24-48hrs.
BLISTERS:
Circumscribed elevated, superficial fluid filled
cavity. If <0.5cm it is a vesicle; >0.5cm a bulla

PETECHIAE :
pin head sized macules of blood.
PURPURA:
large petechiae which do not blanch on pressure.
ECCHYMOSIS:
large extravasation of blood in the skin.

• COMMON:
Measles
Rubella
Dengue
Roseola infantum
Erythema infectiosum
Drug rash
Adenoviral or enteroviral infections.

•Less common:
IMN
Chikungunya
HIV
Typhus
CMV

Eruptive (rash) phase: Rash appears on 4-6 day of fever.
MORPHOLOGY- Faint erythematous maculopapular rash.
DISTRIBUTION-
Starts behind the ears, involving the face & spreading
to trunk& then to legs and arms.
By the time it appears on feet ,it starts disappearing
from face in the same order.
Temperature normalises once rash starts fading.
Severity is proportionate extent & confluence of rash.

PRODROME:
low grade fever
Malaise
sorethroat
Post auricular, sub-occipital lymph nodes :enlarged &
tender.
Rose spots on soft palate (forchheimer spots)before rash.
RASH
MORPHOLOGY
Discrete maculopapular rash variable in size and
confluence.
DISTRIBUTION
Starts on face & spreads rapidly over trunk.
Progression is fast. By 3rd day rash clears up without
significant desquamation.

MEASLES (RUBEOLA) GERMAN MEASLES (RUBELLA)
Coryza &cough more severe. Coryza & cough mild
Confluent maculopapular rash with
slow progression and clearing.
Discrete maculopapular rash with
rapid progression and clearing.
Temperature rises abruptly with rash . Temperature don’t rise abruptly with
rash.
Lymphadenopathy not characteristic Retro-auricular, post . Cervical or
post.occipital lymphadenopathy is
characteristic.
Kopliks spots may be seen Forschheimers spots may be seen.

Rashes are seen in febrile phase and during convalscence.
FEBRILE PHASE:
During fever, whole body invariably covered with
bloachable erythematous flush.
Suffused & swollen face, injected eyes, reddened
ears,crimson malar area,swollen & purplish lips(measly
look).
Flush deepens with advancing disease.
In few patients, maculopapular exanthem erupt on top of
erythematous flush.

Hemorrhagic manifestations include petechiae and mucous
membrane bleed.
Early febrile phase shows positive torniquet test.
RECOVERY PHASE: (CONVALSCENCE)
Termination of illness is swift, marked by a distinctive
acral exanthem.
Bright red confluent petechial rash along lateral
margins of soles and palms.
In some areas there are small round areas of clear skin
giving it a name of annular petechial rash.(white isles in
sea of red).

• IT IS ALSO KNOWN AS TOURNIQUET TEST.
• Part of new WHO case definition of dengue.
• Marker of capillary fragility.
• Steps:
• Take patients BP.
• Inflate the cuff to a point midway between SBP & DBP and maintai
• Reduce and wait 2min.
• Count petechiae below antecubital fossa.
• A POSITIVE TEST IS 20 PETECHIAE PER 1 SQUARE INCH.

ROSEOLA INFANTUM(sixth disease) –
Herpes virus 6,7
rash with defervescence.
ERYTHEMA INFECTIOSUM(fifth disease):
Parvovirus p19
Slap cheek appearance.
Maculopapular rash on extensor aspect.
IMN:
Rash appears after giving ampicillin (20% children)
CHIKUNGUNYA:
Rashes are seen on the trunks & limbs; also on
face,palms & soles.
Petechiae occur alone or in association with rash.

ROSEOLA
ERYTHEMA INFECTIOSU
IMN
CHIKUNGUNYA

• COMMON:
Chicken pox
Hand foot mouth disease.
• LESS COMMON:
Herpes simplex
Herpes zoster
Papulo necrotic tuberculosis.

• CHICKEN POX:
Moderate fever -- 2-3 days; maculopapular rash
 MORPHOLOGY:
After appears which later turns into vesicles filled with
clear fluid which becomes cloudy & umblicated (dew drops
on rose petals)
Intensely pruritic.
DISTRIBUTION:
predominant on flexor surfaces.
• Palms& soles are seldom affected.
Pleomorphic.

HERPES ZOSTER:
Uncommon in children. Reactivation of latent VZV.
MORPHOLOGY:
clustered vesicular rash on erythematous base.
DISTRIBUTION: 1 OR 2 dermatomes.

• HAND FOOT MOUTH DISEASE.
• Caused by viruses of genus enterovirus.
• Rash is seen on palms and soles; less commonly on
flexors.

COMMON:
Meningococcemia
Henoch schonlein purpura.
DHF.
LESS COMMON:
Hemorrhagic measles.
Gonococcemia
Cutaneous vasculitis .
Indian spotted fever.

• HSP:
• Common vasculitic disorder of childhood.
• Non-thrombocytopenic palpable purpura.
• Rash over the extensor aspects of lower extremities and
buttocks.
• MENINGOCOCCEMIA:
• Rashes starts as scattering of small pin prick marks.(reddish or
brown).
• Later large patches of purple or red blotches or blood blisters.
• Will not blanch with pressure.

COMMON:
• Kawasaki disease.
• TEN(Toxic epidermal necrolysis)
• SJS
LESS COMMON:
• TScarlet fever.
• SS.

This sign is present when slight rubbing of the skin results
in exfoliation of the skin in its outermost layer.
Formation of new blisters in slght pressure (Direct Nikolsky)
Shearing of skin due to rubbing (Indirect Nikolsky )

• TOXIC EPIDERMAL NECROLYSIS:
• Immune complex mediated.
• Skin lesions begin as hot,tender,erythematous,morbilliform or
descrete macules that rapidly coalesce & become patches of
loose skin.

KAWASAKI DISEASE:
 Necrotizing vasculitis of medium sized muscular arteries
(coronaries).
 fever atleast 5days.
 Edema , erythema of hands & feet.
 Periungual desquamation.
 Polymorphous rash (never vesicular).
 Strawberry tongue.

COMMON:
Scabies
Insect bites.
LESS COMMON:
Cutaneous larva migrans due to
hookworm,strongyloids,pediculosis.

COMMON:
Erythema nodosum due to TB
Drugs (penicillin,sulphonamides, anticonvulsants,
anti TB ,gentamicin).
Molluscum contagiosum
Lepromatous leprosy.
LESS COMMON:
Disseminated histoplasmosis
cryptococcosis.

• 1st DAY – Varicella.
• 2nd DAY- Scarlet fever.
• 3rd DAY- Small pox
• 4th DAY- Measles.
• 5th DAY – Typhoid
• 6th DAY-Dengue
• 7th DAY- Typhus.

• Complete haemogram
• Urine microbiology
• Blood biochemistry.
• Smear examination from skin lesion.
• Gram/leishman/AFB staining.
• Dark field microscopy.
• LE cell test.
• Blood serology
• Skin biopsy.

Approach to a child with fever and rash

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