This document provides guidance on evaluating a child presenting with fever and rash. It describes the key characteristics of fever and rash, important aspects of history and physical exam, and the differential diagnosis for common infectious and inflammatory causes of fever and rash in children. These include viral illnesses like measles, chickenpox, rubella, scarlet fever, dengue fever, and typhoid fever, as well as bacterial infections like Kawasaki disease, systemic lupus erythematosus, and infectious mononucleosis. Diagnosis and treatment options are outlined for each condition. A thorough history, physical exam focusing on rash characteristics, and diagnostic testing can help identify the underlying cause.

1. APPROACH TO A
THE CHILD WITH A
FEVER AND RASH
Maryam Majid Al Ezairej
RAKMHSU

2.  What is fever?
Fever means a temperature above 100.4ºF (38ºC). Its a
normal response to a variety of conditions, the most
common of which is infection.

3. o What is rash?
A rash is a change of the human skin which affects its
color, appearance, or texture. A rash may be localized in
one part of the body, or affect all the skin.

4. 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)

5. Common skin lesions
 Macule: non palpable, 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
 Vesicle: fluid-filled, elevated skin lesion (<1 cm in
diameter)
 Bulla: fluid-filled, elevated skin lesion (>1 cm in
diameter)
 Pustule: pus-containing vesicle

8. History
 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

9. Physical examination
 a)
 Distribution pattern
 - symmetrical eruption
 - asymmetrical rashes
 b)
 Morphology
 - monomorphic
 - pleomorphic
 c)
 Configuration
 - linear, annular, grouped,
 - Koebner phenomenon (eruption in an area
 local trauma)

14. Differential Diagnosis
Infectious causes
1. Measles:
– Blanching erythematous maculopapular rash
– Begins in head and neck à spreads centrifugally to trunk
and extremities
– Associated symptoms: fever, cough, coryza and
conjunctivitis
_Diagnosis: measeles IgM is detectable for 1 mon after
illness
_Treatment: Supportive

17. Chickenpox
– Initially as small red papules that rapidly progress to
oval, non umbilicated,“teardrop” vesicles on erythematous
base.
– Lesions are present in different stages: papules,
vesicles, crusting
_New crops appear for 3 to 4 days, beginning on the trunk
followed by the head, the face, and, less commonly, the
extremities
_PCR is the current diagnostic method of choice.
_ Treatment: Supportive

18. Dew drop on a
rose petal

19. Rubella
– Rash resembles measles, but patient is not ill looking
– Prominent posta uricular, posterior cervical +/-
suboccipital adenopathy
– Forschemier spots: small, red spots (petechiae) on soft
palate in 20% of rubella patients
_Ig M antibodies diagnostic for congenital rubella syndrome
_Treatment: Supportive

20. forschheimer spots

21. 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.
_diagnosis: group A Streptococcus is present in throat swab.
_Treatment: rehydration, antibiotics(Amoxicillin 40 mg per
kg per day).

22. strawberry tongue

23. Dengue Fever
 Dengue fever is a tropical, mosquito-borne( by female Aedes
aegypti ) disease that causes flu-like symptoms, rashes and joint
and muscle pain.
 High fever of 106°F (41°C)
 Skin rash, which appears three to four days after the onset of fever
 Eye and joint aches
 Backaches and headaches
 Loss of appetite
 Nausea and Vomiting
 Bleeding nose and gums
 Diagnosis: by isolation of the virus, by serological tests.
 Treatment: supportive.

24. Typhoid fever
 Is a bacterial infection caused by salmonella. Which is
common in countries with poor sanitation.
 Persistent fever that rises gradually to 39ºC to 40ºC
(102ºF to 104ºF)
 Temporary rash 2 to 4 mm in diameter with raised pink
blanching spots on the stomach or chest.
 Headache and sore throat
 Tiredness and low energy
 Stomach pain, Constipation, and diarrhea
 Diagnosis: blood and stool culture.
 Treatment: rehydration and cephalosporin.

26. Typhus
 Is a disease caused by infection of rickettsial bacteria and is
transmitted by invertebrate animals known as arthropods. Presents
with:
 severe headache
 high fever (above 102.2°F)
 rash that begins on the back or chest and spreads
 Confusion and Stupor
 Hypotension
 eye sensitivity to bright lights
 severe muscle pain
 Diagnosis: skin biopsy of rash ,Western blot and
immunofluorescence test.
 Treatment: Doxycycline

28. Inflammatory causes
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
_Treatment: intravenous immunoglobulin (IVIG) and Aspirin

30. Systemic Lupus Erythromatosis
– an autoimmune disease in which the body's immune system
mistakenly attacks healthy tissue in many parts of the body
_ Pleuritis or pericarditis
_ Discoid rash which affects the skin, causing a red, scaly rash
with raised borders on areas of the body that are exposed to
sunlight
_ Malar rash and photosensitive rash
_ Oral (Ulcers)
– Arthritis.
_Anemia, leukopenia, lymphopenia orthrombocytopenia
– Renal Nephritis
_Diagnosis: ANA, Immunoreactive (anti-Ds DNA, Anti-Rho,
Anti-Sm, Anti-La, antiphospholipid)

32. Infectious mononucleosis

33. Presentation
 Fever
 Malaise
 Tonsillopharygitis – often severe, limiting oral ingestion
of fluids and food, rarely breathing can be
compromised
 Lymphadenopathy – prominent cervical lymph nodes
 Petechiae on the soft palate
 Splenomegaly (50%), hepatomegaly (10%)
 Maculopapular rash (5%)

34. Treatment
 Medical Care
 Closely monitor patients with extreme tonsillar
enlargement for airway obstruction. Steroids are indicated
for impending or established airway obstruction in
individuals with Epstein-Barr virus (EBV) infectious
mononucleosis.
 Surgical Care
 Surgery is necessary for spontaneous splenic rupture, which
occurs in rare patients with EBV infectious mononucleosis
and may be the initial manifestation of the condition.

35. References
o Nelson book.