Hot Spots (Or Red Rashes With Fever)

Yasmin Tyler-Hill, M.D.

Clinical Assistant Professor Department of Pediatrics Morehouse School of Medicine

Objectives

• • Recognize rashes that are included in the differential diagnosis of Rheumatologic diseases Differentiate common and uncommon but serious diseases that present with fever and rash

…So, What Hot Spots Do We Visit

• • • • • • • Kawasaki’s Steven’s Johnson Rocky Mounted Spotted Fever Measles Group A Strep/Toxic Shock Syndrome Henoch Schoenlein Purpura Roseola

Case #2

• • 20 month old female presents to your office with a 5 day history of fever and irritability. She was seen in the local ER 3 days ago and was given Amoxicillin for an ear infection. Mom stopped the amoxicillin this morning secondary to a rash.

What do you want to know?

Case #1

• HPI: Temperature up to 103. Mother is using Tylenol and Motrin with relief, but the fever returns. Child also has been more irritable than usual, difficult to console. He has been drinking less with decrease urine output

Case #1

• • • • • • • • ROS : • • • Fever (104) Irritability Decreased PO intake Decreased UOP Rash Vomited x 1 NO diarrhea NO SOB NO pain No sick contacts • • • FH • • Sickle cell trait Asthma SH • • • Lives with mom and dad Only child Attends daycare Immunization • UTD

Case #1 Physical Exam

• • • Vital Signs: • T: 39 HR: 138 RR: 30 BP: 90/50 HEENT: NCAT, slightly dry / cracked MM, injected conjunctiva, normal turbinates, TM’s erythematous bilaterally, OP with erythematous tongue and white tonsilar exudate Neck- bilateral cervical lymphadenopathy (1.5 cm on right and 0.5 cm on the left)

Case #1 Physical Exam (Cont.)

• • • • • • • Lungs: CTA bilaterally, no wheezes, no rales CV: Tachycardic , normal rhythm, pulse 2+ Abdomen: soft, NTND, good bowel sounds Skin: red, blanching, slightly raised, polymorphous rash over her extremities Neurological: irritable, difficult to console Genitalia: normal female, desquamation of the area Extremities/ MS- FROM, puffy hands,

Case 1# Physical Exam

Case #1 Laboratory Evaluation

• • • • • WBC 15,000 • 20 bands, 52 neutrophils, 22 lymph, 6 monocytes H/H 9.7/ 30. Platelets 700,000 UA – sp.grav 1.030, ketones 2+ Electrolytes- normal Blood Culture, Urine culture, ? CSF culture

Kawasaki Disease

• • • • • • Epidemiology • Affects all races, seen throughout the world (Asian descent affected more often) 80% in children less than 5, rarely teenager and adults Boys: Girls = 1.5:1 In US about 3000 children hospitalized annually 0.4%-2.0% mortality rate 20-25% with cardiac complications

Case #1 Diagnosis and Treatment

• • • • • Diagnosed with Kawasaki disease • Kawasaki disease is a generalized, acute vasculitis of unknown cause Received IVIG Started on Aspirin Cardiac Echo Improved within 12 hours

Kawasaki Disease: Clinical Diagnosis

• FEVER plus 4 of the 5 • Bilateral, non exudative conjunctival injection • • • • injected or fissured lips, injected pharynx, or strawberry tongue erythema of palms or soles, edema of hands or feet, or periungual desquamation Polymorphous exanthem Acute, nonsuppurative cervical lymphadenopathy (at least one node ≥1.5 cm in diameter)

Kawasaki Disease: Evaluation

• • • • Three phases Although no specific “test”, abnormal labs seen are leukocytosis, elevated erythrocyte sedimentation rate, thrombocytosis, and sterile pyuria. Unknown cause Morbidity and Mortality related to coronary artery thrombosis in 20 25% of children

Kawasaki Disease: Management

• • • • IVIG High dose Aspirin Cardiac Echo Follow -up

Case #2

This 8 year old girl developed upper respiratory symptoms with fever, cough, tachypnea, and malaise several days before a purulent conjunctivitis, erosive oral mucositis, and blistering skin rash. The cutaneous lesions were relatively limited, and the oral lesions and conjunctivitis began to improve 3 to 4 days later. Rapid diagnostic tests for Mycoplasma pneumoniae were positive. Interestingly, her mother had a history of pneumonia treated with oral antibiotics several weeks earlier, and her sister developed a cough and mild but similar rash several days after the patient was hospitalized.

Purulent conjunctivitis with edematous lids and conjunctival hemorrhage, cheek and chin vesicles, intranasal and lip erosions

Diffuse red macules many with central necrotic bulla and erosions and associated conjunctivitis and mucositis

Bullae and erosions on lips, mouth, and scattered on skin

Diffuse red papules and plaques some with central necrotic bullae, erosions of the conjunctivae and oral mucosa

Stevens-Johnson Syndrome

• • • • Cell mediated hypersensitivity response Clinical Presentation • Multiorgan/systmem involment –eye, kidney, liver • Skin and mucosal Precipitating Factors • Drugs –Abx & anticonvulsants • Infective agents –Mycoplasma &herpes simplex Management

A diffuse scarlatiniform eruption developed on this 4-year-old boy who demonstrates his strawberry red tongue and red and fine scaly papular rash. A throat culture was positive for Group A beta-hemoplytic Streptococcus

A healthy 6-year-old boy developed a diffuse papular eruption in association with headache, sore throad, and fever. His throat culture was positive for Group A beta-hemolytic streptococcus, and he improved within several days on oral amoxacillin.

Peeling with minimal underlying erythema This 4-year-old boy with a history of atopic dermatitis was treated for right sided mastitis with topical mupirocin ointment. He subsequently developed a disseminated red sand paperlike eruption. A throat culture was positive for Group A beta-hemolytic streptococcus, and he was treated with oral erythromycin because of a history of penecillin allergy. He subsequently developed widespread desquamation with the most prominent lesions on the hands and feet.

This 8-year-old girl developed a red papular eruption on her lower extremities and a disseminated sandpaper-like rash 3 days after the onset of a sore throat with a positive Group A beta hemolytic streptococcus culture. She also had a strawberry tongue with a white membrane and prominent red papillae poking through the coating.

Group A Streptococcal Infections

• • Clinical Manifestations • Respiratory • Skin • • Other Sequelae Management • Diagnosis • Treatment

Proposed Case Definition for the Streptococcal Toxic Shock Syndrome

• • Isolation of group A streptococci • Hypotension: systolic blood pressure 90 mm Hg in adults or <5th percentile for age in children AND • Two or more of the following signs

− − − − − −

Renal impairment Coagulopathy: Liver involvement Adult respiratory distress syndrome A generalized erythematous macular rash that may desquamate Soft-tissue necrosis, including necrotizing fascitis or myositis, or gangrene

Case # 3

This healthy 10-year-old girl developed purpuric papules consistent with a leukocytoclastic vasculitis on her distal extremities several weeks after a viral upper respiratory infection. She had migratory swelling of the hands and feet and intermittent crampy abdominal pain. Her urinalysis and blood pressure were normal. A skin biopsy from a lesion on the top of the foot showed a leukocytoclastic vasculitis, and direct immunofluorescence demonstrated deposition of IgA around dermal blood vessels.

Case # 4

A 6-year-old boy comes to your office because of migratory pain and swelling of his joints. Three days ago he experienced pain and swelling of his right hand and knee. The following day, the pain and swelling had spread to his right ankle. He complains now only of right ankle and lower back pain. The joints were warm, but no erythema was noted. The child has been healthy, with no history of fever, runny nose, cough, vomiting, sore throat, or diarrhea. He was bitten by a tick 4 months ago. There is no family history of arthritis.

Physical examination reveals a friendly boy in no obvious distress. His vital signs, including blood pressure, are normal, as are the results of his entire examination, except for marked swelling, erythema, and tenderness of the right ankle, which has limited range of motion. There is tenderness on palpation of the sacroiliac joints, but no obvious swelling or limitation of motion is appreciated.

There are no rashes.

Laboratory testing reveals: white blood cell count, 13.2 mmol/L (14.4 g/dL); platelet count, 306 x 10 9 /L (306 x x 10 9 /L (13.2

x 10 3 /mcL); hemoglobin, 8.93 10 3 /mcL); erythrocyte sedimentation rate, 11 mm/hr; normal findings on urinalysis; negative throat culture, anti-streptolysin O titer, anti-DNAse B titer, Lyme titer, mononucleosis test, and Epstein-Barr titers. Radiographs of the right ankle and lumbosacral spine show no bony abnormalities.

Case # 4 (con’t.)

Upon his return to the office, the boy was noted to have a purple, papular rash on his buttocks and lower extremities and was experiencing severe abdominal pain and swelling of his left elbow, a constellation of findings characteristic of

Henoch

Schöenlein purpura (HSP).

Henoch-Schoenlein Purpura

• Leucocytoclastic vasculitis • Clinical Presentation

− − − −

Rash, angioedema Arthritis or arthralgias GI

– –

50% of affected children Colicky abd pain, GI bleeding, rarely intussusception Kidney disease

–

25-50%

–

Hematuria –endstage renal disease • Management

Case # 5

A healthy 14 month old developed a red papular morbilliform eruption after 3 days of high fever without a source. The rash begin at his head and spread distally. The rash cleared in the same manner. The asymptomatic rash appeared as he deffervesced and lasted less than 24 hours.

Case # 6

A 9-month-old girl is brought to the clinic because of worsening fever and rash. Three days ago, she developed a fever of 38.8

°C (101.8°F) and pinpoint flesh-colored "bumps" on the abdomen. The rash soon turned red and quickly spread to the entire body, but it was not pruritic. The following day she developed clear rhinorrhea and a cough severe enough to cause posttussive emesis. The fever persisted for the next 2 days despite administration of ibuprofen. The increasing irritability and fever of 40.0

°C (104°F) prompted her mother to bring her to the clinic. The child’s appetite is poor, but she does drink, and her urine output has not diminished. There is no diarrhea. Her mother denies administering any medication other than ibuprofen. The child has been healthy previously, and her mother is unaware of any known illness contacts. She has received her primary immunization series for diphtheria, tetanus, pertussis, polio,

Haemophilus influenzae

type b, and hepatitis B. Of note, she and her family traveled cross-country by automobile 2 weeks ago.

Case mealses

Physical examination reveals an irritable but consolable infant who has a red rash consisting of raised spots and flat, confluent patches (Fig. 1 ). She has a temperature of 38.3

°C (101.8°F), respiratory rate of 42 breaths/min, and pulse of 152 beats/min. Discrete, intensely red, raised lesions extend over the face (Fig. 2 ), trunk, and extremities. Flat, red spots appear on the palmar surfaces (Fig. 3 ). No blisters or small, purple hemorrhages of the skin are present. Examination of the head shows conjunctival injection without discharge; clear rhinorrhea; two grayish white, pinpoint, elevated spots on the right buccal mucosa; and palpable, mobile lymph nodes in the posterior cervical regions. Auscultation of the chest demonstrates bilateral clear breath sounds and normal S1 and S2 heart sounds without a murmur. Findings on abdominal, genitourinary, and neurologic examinations are unremarkable.

Mealses

• Epidemiology

−

Occurs in unimmunized preschoolers and teens missing 2 nd immunizaation • Clinical Presentation

− −

Incubation stage (10-12 days) Prodromal stage (3-5 days)

–

Koplick spots, conjunctivits, coryza, fever, cough

−

Exanthem Stage

–

Red macular papular rash, high fever • Complications

–

Pneumonia, croup, OM, acute and subacute encephalitis, • Transmission

–

Highly contagious

Rocky Mounted Spotted Fever

This 9 year old boy developed a red partially blanching papular eruption on his hands and feet including his palms and soles that progressed to the trunk over 3 days. He had a severe headache, high fever, arthralgias and myalgias. His mother, who remembered removing a wood tick from her son's scalp 10 days earlier also developed a rash, fever, and headache.

An ill appearing toddler with high fever and a diffuse red rash and edema suddenly developed diffuse petechiae and ecchymoses. Laboratory studies showed a prolonged bleeding time, thrombocytopenia, anemia, and neutropenia. After a prolonged course in the pediatric intensive care unit, he recovered uneventfully with the exception of necrosis of the tips of several toes.

Large (8 m body) 8-legged arachnid; black with brown leather pattern on body and legs In the United States the most common vectors of Rickettsia rickettsii include Dermacentor variabilis (American dog tick), Dermacentor andersoni (wood tick), and Amblyomma americanum

Rocky Mounted Spotted Fever

− − − −

Rickettsia rickettsii gram neg intracellular coccobacillus Clinical Presentation

– –

HA, myalgias followed by rash on day3-5 Systemic conjunctivitis,hypotension,renal,CNS,coagu lopathy Diagnosis

–

Indirect Fluorescent Antibody—6-10 days into illnes

– –

PCR specific not sensitive Bx—need expert for correct interpretation Treatment

– – –

Doxycycline for all ages Chloramphenicol Duration 7-10 days

References

– – – – – L. Akinbami and Tina L. Cheng

Rocky Mountain Spotted Fever

Pediatr. Rev., May 1998; 19: 171 - 172. Theoklis Zaoutis and Joel D. Klein

Enterovirus Infections

Pediatr. Rev., Jun 1998; 19: 183 - 191.

Anjali Jain and Robert S. Daum

Staphylococcal Infections in Children: Part 3

Pediatr. Rev., Aug 1999; 20: 261 - 265.

Muhammad Waseem and Heidi Pinkert

Visual Diagnosis: A Febrile Child Who Has "Red Eyes" and a Rash

Pediatr. Rev., Jul 2003; 24: 245 - 248. http://dermatlas.med.jhmi.edu/derm/