Approach to Fever with Rashes in Children
Introduction to Pediatric Fever with Rash
Key Concepts
- Definition: Temperature >38.0°C (100.4°F) with cutaneous manifestations
- Epidemiology: Accounts for 10-15% of pediatric emergency visits
- Age distribution: Most common in children 6 months to 5 years
- Seasonal variation: Higher incidence during summer and winter months
Initial Assessment Priorities
- Vital sign stability assessment
- General appearance evaluation
- Rash characteristics documentation
- Fever pattern analysis
- Associated symptom identification
Classification & Etiology
Based on Timing
- Fever First Pattern
- Roseola infantum
- Scarlet fever
- Drug reactions
- Kawasaki disease
- Simultaneous Fever and Rash
- Measles
- Rubella
- Meningococcemia
- Toxic shock syndrome
- Rash First Pattern
- Erythema infectiosum
- Hand-foot-mouth disease
Based on Morphology
- Maculopapular Rashes
- Viral exanthems
- Drug eruptions
- Early meningococcemia
- Kawasaki disease
- Vesiculobullous Rashes
- Varicella
- Herpes simplex
- Hand-foot-mouth disease
- Bullous impetigo
- Petechial/Purpuric Rashes
- Meningococcemia
- Rocky Mountain spotted fever
- Henoch-Schönlein purpura
- Viral infections with thrombocytopenia
Clinical Evaluation
History Taking Elements
- Fever Characteristics
- Onset and duration
- Pattern and peak temperature
- Response to antipyretics
- Associated symptoms
- Rash Description
- Time of onset relative to fever
- Initial site and spread pattern
- Evolution of lesions
- Associated symptoms (pruritus, pain)
- Risk Assessment
- Immunization status
- Recent medications
- Exposure history
- Recent travel
- Sick contacts
Physical Examination Focus
- Vital Signs Assessment
- Temperature measurement method
- Heart rate and respiratory rate
- Blood pressure and perfusion
- Oxygen saturation
- Rash Characteristics
- Distribution pattern
- Morphological features
- Color and texture
- Blanching vs non-blanching
- Associated findings (warmth, tenderness)
Common Conditions
Viral Exanthems
- Measles
- Koplik spots precede rash
- Cephalocaudal progression
- Associated with cough, coryza, conjunctivitis
- Complications: pneumonia, encephalitis
- Roseola Infantum
- High fever for 3-5 days
- Rash appears as fever resolves
- Rose-pink blanching macules
- Mainly affects infants 6-24 months
- Hand-Foot-Mouth Disease
- Vesicular lesions on extremities
- Oral ulcers common
- Usually affects children <5 years
- Self-limiting course
Bacterial Infections
- Scarlet Fever
- Sandpaper-like rash
- Strawberry tongue
- Pastia lines in skin folds
- Associated with Group A Strep infection
Emergency Conditions
Life-Threatening Presentations
- Meningococcemia
- Rapid progression
- Petechiae/purpura
- Signs of shock
- High mortality if untreated
- Immediate antibiotic needed
- Toxic Shock Syndrome
- Diffuse erythema
- Hypotension
- Multi-organ involvement
- Desquamation in recovery
- Stevens-Johnson Syndrome
- Severe mucocutaneous reaction
- Usually drug-induced
- Extensive skin involvement
- High mortality risk
Red Flag Signs
- Non-blanching purpuric rash
- Altered mental status
- Poor peripheral perfusion
- Respiratory distress
- Severe pain
- Toxic appearance
Management Principles
Initial Stabilization
- ABCs Assessment
- Airway patency
- Breathing adequacy
- Circulation status
- Emergency Interventions
- IV access establishment
- Fluid resuscitation if needed
- Oxygen supplementation
- Temperature management
Diagnostic Workup
- Basic Investigations
- Complete blood count
- C-reactive protein
- Blood culture
- Throat swab if indicated
- Specific Testing Based on Suspicion
- Viral studies
- Autoimmune markers
- Imaging studies
