A pediatric patient presented with fever and a rash, which can indicate various illnesses ranging from minor to life-threatening. The differential diagnosis for febrile patients with a rash is extensive, including viral, bacterial, and other infectious etiologies. Proper evaluation and management of these patients is important as the severity of illness can vary greatly.

1. Evaluating the Febrile Patient with a
rash
D. TAREK SAYED
pediatric departement
MCH Buraydah

2. 
The differential diagnosis for febrile patients
with a rash is extensive.

3. causes
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viruses
bacteria
infectious
Spirochetes
rickettsiae
Medications
rheumatologic diseases
Allergic
Non
infectios

4. Rashes can be categorized as:
- maculopapular
-petechial
- diffusely erythematous with desquamation
-vesicular
-bullous
-pustular
-nodular

5. Because the severity of these illnesses can
vary from minor (roseola) to life-threatening
(meningococcemia), the physician must
make prompt management decisions regarding
imperical theraby.

6. 
Evaluating the patient who presents with
fever and a rash can be challenging
because the differential diagnosis is
extensive and includes minor and lifethreatening illnesses

7. 

Ringworm
Worms don't cause ringworm.
It's caused by a fungus that
lives off dead skin, hair, and
nail tissue. It starts as a
red, scaly patch or bump. Then
comes the telltale itchy red ring.
The ring has raised, blistery, or
scaly borders. Ringworm is
passed on by skin-to-skin
contact with a person or animal.
Kids can also get it by sharing
things like towels or sports
gear. You may treat it with
antifungal creams.

8. 

Fifth Disease
This contagious and usually mild
illness passes in a couple of
weeks. Fifth disease starts with
flu-like symptoms. A bright face
and body rash follow. It’s spread
by coughing and sneezing and
most contagious the week before
the rash appears. It's treated with
rest, fluids, and pain relievers (do
not give aspirin to children). If
your child has fifth disease and
you are pregnant, call your doctor.

9. 

Chickenpox
This once-common rash isn't seen
as much in today's kids thanks to
the chickenpox vaccine. It’s very
contagious, spreads easily, and
leaves an itchy rash and red spots
or blisters all over the body. The
spots go through stages. They
blister, burst, dry, and crust over.
Chickenpox can be very serious.
All young kids should get a
chickenpox vaccine. So should
teens and adults who never had it
or the shot.

10. 

Impetigo
Impetigo, caused by
bacteria, creates red sores or
blisters. These can break
open, ooze, and develop a yellowbrown crust. Sores can show up
all over the body but mostly
around the mouth and nose.
Impetigo can be spread through
close contact or by sharing things
like towels and toys. Scratching
can spread it to other parts of the
body. It's treated with antibiotic
ointment or pills.

11. 

Warts
A virus causes these funky but
mostly harmless, painless skin
growths. Warts can spread easily
from person to person. They also
spread by touching an object used
by a person with the virus. They're
most often found on fingers and
hands. To prevent warts from
spreading, tell your child not to
pick them or bite nails. Cover
warts with bandages. Most warts
go away on their own.

12. 

Contact Dermatitis
Some kids' skin reacts after
touching foods, soaps, or plants
like poison ivy, sumac, or oak. The
rash usually starts within 48 hours
after skin contact. Minor cases
may cause mild redness or a rash
of small red bumps. In severe
cases you may see
swelling, redness, and larger
blisters. This rash goes away after
a week or two or when contact
ends.

13. 

Hand-Foot-Mouth Disease
(Coxsackie)
Despite its scary name, this is a
common childhood illness. It starts
with a fever, followed by painful
mouth sores and a non-itchy rash.
The rash blisters on hands, feet,
and sometimes buttocks and legs.
It spreads through coughing,
sneezing, and used diapers. So
wash hands often. Coxsackie isn’t
serious and usually goes away on
its own in about a week.

14. 
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Eczema
Kids prone to eczema may have
other allergies and asthma. The
exact cause isn't clear. But kids
who get it tend to have a sensitive
immune system. Watch for a
raised rash with dry skin and
intense itching. Atopic dermatitis is
the most common type of eczema.
Some children outgrow it or have
milder cases as they get older.

15. 

Hives
Many things can trigger these itchy or
burning welts. Medicines such as
aspirin (which kids should never take)
and penicillin can set off hives. Food
triggers include
eggs, nuts, shellfish, and food
additives. Heat or cold and strep throat
can also cause hives. Welts can show
up anywhere on the body and last
minutes or days. Sometimes an
antihistamine can help. Hives can be a
sign of serious problems, especially
when they come with breathing
troubles or swelling in the face. In
those cases or if hives don't go
away, see your doctor.

16. 

Scarlet Fever
Scarlet fever is strep throat with a
rash. Symptoms include sore
throat, fever, headache, belly pain,
and swollen neck glands. After 1-2
days, a red rash with a sandpaper
texture shows up. After 7-14 days,
the rash rubs off. Scarlet fever is
very contagious, so wash hands
often to keep it from spreading.
Call your child's doctor if you think
your child has it. He'll probably be
treated with with antibiotics.

17. 

Roseola (Sixth Disease)
Roseola, a mild illness, gets its
nickname from a list of six
common childhood rashes. Young
kids 6 months to 2 years are most
likely to get it. It's rare after age 4.
It starts with a cold, followed by a
few days of high fever (which can
trigger seizures). Then the fevers
end suddenly. They're followed by
a rash of small, pink, flat, or
slightly raised bumps. It shows up
first on the chest and back, then
hands and feet.

18. 
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Rubella (German Measles)
Rubella, also called German
measles, is a mild virus that
usually causes no serious
problems. However, it can harm
the fetus if a pregnant woman
becomes infected. The symptoms
are a low fever and rash that
spreads from the face to the rest
of the body. A standard childhood
vaccine called MMR protects
against measles, mumps, and
rubella.

19. 
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Lyme Disease
The hallmark of Lyme disease is a
target-shaped rash that appears
1-2 weeks after a tick bite, though
not everyone will develop the
distinctive rash. The rash may be
accompanied by a
fever, chills, and body aches. The
culprit is a type of bacterium
carried by tiny deer ticks. Without
treatment, Lyme disease can
affect the joints, nervous
system, and heart.

20. 
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Molluscum Contagiosum
Signs: This contagious rash
shows up as one or more
flesh-colored, raised bumps
that are about the size of a
pimple. The center of each
bump has a tiny dimple. The
rash usually shows up on the
face, arms, and legs

21. 
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Diaper Rash With Yeast
Infection
Signs: This red, raised rash
shows up in the groin, around
the genitals, in the creases of
the hips, or on the buttocks. It
itches or irritates. Signs of an
accompanying yeast infection
are round, red spots separate
from but near the main rash.

22. 

Kawasaki Disease
Kawasaki disease is a very rare
and mysterious ailment that
strikes children under age 5. The
symptoms include a high
fever, patchy rash, swelling and
redness of the hands and
feet, bloodshot eyes, and
chapped, red lips. Without
treatment, the illness can damage
the heart and may be fatal.
Doctors have yet to discover what
causes Kawasaki disease.

23. •
•
•
•
•
•
A child is brought into his pediatrician's
office after developing a diffuse rash.
His parents do not believe in
vaccinations. You suspect that the
child has developed measles. All of the
following are true about measles
EXCEPT:
A. Measles is a leading cause of death
in young children worldwide
B. The classic triad is
cough, coryza, and conjunctivitis
C. Koplik spots are pathognomonic
white spots that appear on the buccal
cheeks
D. A major early complication is acute
sclerosing panencephalitis
E. Since the introduction of the
measles vaccine, the annual incidence
dramatically decreased.

24. 

Measles is one of the most contagious
infectious diseases, with a secondary
infection rate of 90% in susceptible
individuals
it remains one of the leading causes of
death in young children
worldwide, with an estimated 197,000
deaths yearly. After exposure, the
incubation period lasts for 7-14 days.
Patients then develop a prodrome of
high fevers, often > 104 F, with the
classic triad of cough, coryza, and
conjunctivitis. A couple of days
later, Koplik spots develop on the
buccal mucosa, appearing as white
spots on an erythematous base, as
shown.

25. o
o
o
o
o
o
A 4-month-old girl presents to the
ED in extremis with rapidly
developing gangrene of the
extremities. All of the following are
true of meningococcemia
EXCEPT:
A. The mortality rate is 5%-10%
B. Meningitis is present in all
cases of septicemia
C. Empiric antibiotic treatment
should be initiated immediately
D. Transmission is person-toperson by direct contact via
respiratory droplets
E. Gangrene is caused by arterial
occlusion

26. 

The correct answer is B
Meningococcemia is caused by the
gram-negative diplococcusNeisseria
meningitides. Transmission is personto-person via respiratory
droplets, often from an asymptomatic
carrier. Up to 30% of teenagers and
10% of adults carry meningococci in
the upper respiratory tract. The clinical
presentation is variable, with 50% of
patients developing meningitis
only, 10% developing septicemia
only, and 40% developing both.
Children with meningitis are usually
febrile and ill-appearing, with
symptoms of lethargy, vomiting, or
nuchal rigidity. Septicemia leads to
capillary leak, coagulopathy, profound
acidosis, and myocardial failure. Septic
emboli cause arterial occlusion in the
distal extremities, as shown in this
infant.

27. 
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An 11-year-old girl presents with
raised violaceous plaques on her legs
and arms that developed over the last
few days. She has had a temperature
of 100-101 F at home but no other
complaints. Her current temperature is
100.2 F. The rest of her exam is
normal. You conclude that she has
Henoch-Schonlein purpura (HSP).
Which of the following tests are most
appropriate to perform at this point?
A. CBC, lumbar puncture
B. CBC, electrolytes, stool for occult
blood, urinalysis
C. CBC, electrolytes, stool for occult
blood, renal ultrasound
D. CBC, head CT, lumbar
puncture, abdominal ultrasound
E. CBC, abdominal ultrasound

28. 
The correct answer is B. The images
shown are purpuric lesions. In this
case of a healthy-appearing child with
this history and physical
examination, HSP is a reasonable
diagnosis. HSP is a vasculitis that can
affect the skin, joints, gastrointestinal
tract, and kidneys. In a well-appearing
child, HSP can be managed on an
outpatient basis. It is helpful to check
blood pressure, urine, and electrolytes
to look for a glomerulonephritis.
Urinalysis and blood pressure may be
followed for several months to monitor
kidney function. A fecal occult blood
test can help rule out significant gut
involvement, especially in children with
pain. Intussusception is the most
serious complication of HSP; if it is
suspected, the child should be
admitted and monitored.

29. A 3-year-old girl presents with a blistering
rash on her face and body. Her mouth is
pictured above. All of the following are true
statements regarding Stevens-Johnson
syndrome (SJS) EXCEPT:
A. Medications, including nonsteroidal
anti-inflammatory medications (NSAIDs),
sulfonamides, antiepileptics, and
allopurinol, are commonly accepted
triggers
B. Viruses, such as herpes simplex virus,
Epstein-Barr virus, enteroviruses, and
influenza, are accepted triggers
C. Malignancy can be associated with SJS
D. Bacterial etiologies include
mycoplasma and group A beta-hemolytic
streptococcus, among others
E. Idiopathic causes are unlikely

30. 
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The correct answer is E.
SJS may involve the mucous
membranes, including the eyes and
gastrointestinal tract. When more than
30% of the body surface area is
involved, cases are generally referred
to as toxic epidermal necrolysis.
Treatment is symptomatic, including
treatment of superinfection and pain
control. Patients with severe cases
should immediately be fluidresuscitated and treated as burn
victims. Offending agents should be
removed or treated. Use of steroids is
controversial. Involvement of
specialists, including
ophthalmologists, immunologists, and
burn specialists, may be indicated.
Morbidity and mortality are correlated
with the percentage of body surface
area involved

31. 
Staphylococcal scalded skin
syndrome (SSSS) is a disease
that usually affects infants and
young children who lack the
antibodies to Staphylococcus
aureus toxins that adults have. It
is caused by bacterial infection by
group II S. aureus that produces
toxins that cause
exfoliation, bullae (blister)
formation and redness of skin. In
children mortality is low, but can
be high in adults, who will usually
have a serious underlying disease
that makes them susceptible to
infection

32. Thank you