FEVER WITH RASH

IN CHILDREN
DR. RISHWANTH
DEPARTMENT OF PAEDIATRICS & NEONATOLOGY
SPMCH & RI
COMPETENCIES
• INTRODUCTION
• CAUSES
• EPIDEMOLOGY
• CLINICAL FEATURES
• APPROACH
INTRODUCTION
• Fever with rash is common in childhood and a cause of anxiety among
parents.

• Many of them are benign viral exanthems without much clinical

significance.

• Reassurance and supportive therapy are all that is needed in such

cases.
• However, a physician must be aware of the distinguishing features of
the serious illnesses which may be associated with major
complications with substantial morbidity and mortality.

• There are a large number of infectious and noninfectious conditions

presenting as exanthematous fevers.

• Many of them have a characteristic combination of clinical features.

The rash is also morphologically different in different diseases.
CAUSES
EPIDEMOLOGY- Viral exanthems are the most
common cause of fever with rash in children.
• Rubeola or measles - paramyxovirus - droplet infection - 6 months and 3 years
of age – winter and spring

• Dengue fever and Chikungunya fever- arbovirus transmitted by Aedes

egypti mosquito – monsoon - all ages and both sexes are equally affected

• Herpes simplex- all seasons - harbor latent infection responsible for

recurrences

• Parvovirus B19 - respiratory droplets - 4 and 10 years of age - Erythema

infectiosum (EI)
• Varicella and rubella - 3 and 10 years of age – droplet infection

• Human herpes virus 6 (HHV6) and Epstein-Barr virus (EBV) infections -

early infancy and childhood – saliva

• Enteroviruses – round the year - nasal/oral secretions, aerosol droplets

and fecal material

• Hand foot and mouth disease (HFM) - coxsackievirus A16 or

Enterovirus71, coxsackievirus A9, A10, B1,
BACTERIA- VERY DANGEROUS
• Staphylococcal scalded skin syndrome (SSSS) - less than 5 years of age

• Toxic shock syndrome (TSS) - menstruating girls between 15 and 25

years

• Group A streptococci (GAS) - scarlet fever (SF), erysipelas- 2 and 10

years and acute rheumatic fever (RF) - 5 and 15 years of age

• Meningococcal disease is low in India with occasional outbreaks

• Leptospirosis - heavy monsoon, animal rearing practices, and
unplanned urbanization- urine of Rat

• Rickettsial diseases – Rural areas, cattle, dogs, cats - Tics

Non- infectious cause
• Collagen vascular disease - systemic lupus erythematosus (SLE), systemic
onset juvenile chronic arthritis (sJCA), and vasculitis

• Lupus - female preponderance, female to male ratio being 4:1 before puberty
and 8:1 after puberty. Onset of the disease is usually after 8 years

• sJCA - young children often less than 1 year of age with no sex predilection

• Kawasaki disease (KD) - < 5years of age

• Henoch-Schonlein purpura (HSP)- 2-8 years and male to female ratio of 2:1
CLINICAL FEATURES
• Measles
prodromal phase with fever, rhinorrhea, cough, and conjunctival congestion.
Koplik spots consisting of gray white sand-like lesions with surrounding
erythema in the buccal mucosa opposite the lower second molar tooth are
pathognomonic.
Erythematous, confluent, maculopapular rash develops usually on the DAY 4
of fever, beginning behind the ears and forehead and progressing downward.
The rash resolves in the same order with residual brownish discoloration and
desquamation which fades over the next 10 days.
• Rubella

Minute, discrete macules, in contrast to the confluent rash of measles.

The rash appears within 24 hours (DAY 1)of onset prodromal

symptoms, spreads rapidly from face to trunk and extremities and
disappears altogether by the DAY 3

Posterior cervical and postauricular lymphadenopathy

• Varicella

occurs in crops, which evolves through the stages of macule, papule,

vesicle, and crusts involving mainly the trunk and proximal end of
extremities

Fever subsides 2-4 days after appearance of rash and the rash
disappears after 3-7 days, leaving behind hypo- or hyperpigmented
macules persisting for days to weeks.
• Infectious mononucleosis

Fever, pharyngeal inflammation, generalized lymphadenopathy, and

hepatosplenomegaly are associated with a maculopapular rash

Erythema multiforme or urticaria

• Dengue fever

sudden onset of high grade fever associated with facial flushing,

headache, myalgia, arthralgia, and abdominal pain

Within 48 hours of onset of fever, a transient generalized macular rash

develops

Fever may subside after 2-7 days, only to reappear after 1-2 days,
demonstrating the typical biphasic pattern.
• Chikungunya

high fever with rigors, accompanied by intense joint pain, headache,

myalgia, and rash
The arthritis is polyarticular, migratory involving small joints. The joint
pain tends to persist for long

The rash is itchy, transient, maculopapular, distributed over trunk, and

extremities, appearing 4-8 days after fever and arthritis.
• Herpes simplex types 1 and 2

single or grouped vesicles varying from 2 to 10 mm, on a mildly

erythematous base

Fever blisters are the most common presentation of recurrent HSV-1

infection, primarily seen over lips, nose, chin, cheek, or oral mucosa.
• Parvovirus B19
homogenous erythema over the cheeks demonstrating the typical
"slapped cheek" appearance

HFMD disease is most common. After a prodrome of 2-4 days, large (2-
8 mm), oval, gray blisters with erythematous base develop over hands,
feet, and buttocks. Painful aphthous ulcers are seen in the mouth. The
rash resolves in 5-7 days.
BACTERIA
• Staphylococcal infections
Furuncles, carbuncles, folliculitis, bullous impetigo (which may or may not
be associated with fever) to TSS and SSSS (which are associated with high
temperatures).

TSS is an acute multisystem disease characterized by high fever, vomiting,

diarrhea, conjunctival congestion, strawberry tongue and diffuse, dark,
and sunburn-like rash. This is accompanied by altered sensorium,
disseminated intravascular coagulation, and hypotension. Symptoms
resolve by 7-10 days, associated with desquamation of palms and soles.
• Scarlet fever caused by GAS
Rash and strawberry tongue appearing 1-2 days after an upper
respiratory tract infection
The rash is typically diffuse, erythematous, blanchable, and finely
papular (like sandpaper) beginning around the neck spreading over
trunk and extremities, sparing the face. The rash fades with
desquamation after 3-4 days.
• Leptospirosis
Symptomatic children present with a biphasic pattern, beginning with
abrupt onset of high fever with chills, headache, severe tenderness
over lower half of the body, conjunctival suffusion,
hepatosplenomegaly (HSM), and generalized lymphadenopathy (LAD)

After a brief period of well-being, the second phase occurs

characterized by a transient (<24 hours) rash in 10% of cases. The rash
may be urticarial, petechial-purpurial or desquamating type
• Rickettsial fever

fever, headache, myalgia, hepatosplenomegaly, and lymphadenopathy

along with rash.
The rash is macular or maculopapular, occasionally petechial. The
diseases may be associated with a typical painless eschar with an
erythematous rim at the site of vector bite.
NON-INFECTIOUS
• Stevens-Johnson syndrome (SJS) is a serious mucocutaneous illness
with systemic symptoms characterized by the presence of flat,
atypical target lesions epidermal detachment comprising less than
10% of the total body surface area (BSA) and involvement of two or
more mucosal sites.
• TEN is a life-threatening condition characterized by high fever
associated with widespread (involving more than 30% of BSA)
confluent erythema followed by necrolysis.
• An epidermal involvement between 10-30% of BSA has been referred
to as SJS-TEN overlap.
Collagen vascular disease
• low-grade, indolent fever with nonspecific constitutional symptoms
like fatigue, anorexia, and weight loss.
• Children with KD present with a remittent or continuous fever for
about 1-2 weeks without a prodrome of respiratory symptoms. The
acute phase is characterized by erythema and/or edema of hands and
feet, polymorphous erythema over body and extremities, bilateral
nonexudative conjunctival injection, redness, dryness and fissuring of
lips, a strawberry tongue, and nonsuppurative cervical
lymphadenopathy.
DIAGNOSTIC APPROACH
• AGE
• MORPHOLOGY
• ASSOCIATED CLINICAL FEATURES
DISEASE AGE GROUP

Viral exanthems like measles, ES, EBV, and enteroviral below 3 years
infections

KD and SSSS below 5 years

varicella, rubella 3 to 10 years

Meningococcemia less than 5 years and between 15 and 24 years

SLE, JD, RF, PAN, and WG 2 and 8 years

sJCA less than 1 year

dengue and chikungunya all age groups