Approach To A Child With A Fever And Rash

By | April 26, 2017

General Presentation

Children frequently present at the physician’s office or emergency room with a fever and rash. Although the differential diagnosis is very broad, adequate history and physical examination can help the clinician narrow down a list of more probable etiologies. It is important for physicians to be diligent, as the differential diagnosis can include contagious infections or life-threatening diseases. Even though there is a strong link between the presentation of fever and rash and infectious disease, it is important to keep in mind that other non-infectious diseases can also have similar presentations (e.g. drug reactions, cutaneous lupus erythematosus, inflammatory bowel disease).



Features of the rash:

– Characteristic of lesions

– Distribution and progression

– Timing of onset in relation to fever

– Morphological changes (e.g. papules to vesicles)


Common skin lesions:

– Macule: nonpalpable, 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 due to extravasation of RBCs

– Vesicle: fluid-filled, elevated skin lesion (<1 cm in diameter)

– Bulla: fluid-filled, elevated skin lesion (>1 cm in diameter)

– Pustule: pus-containing vesicle

– Ulcer: depressed skin lesion with missing epidermis and upper layer of dermis

Questions to Ask

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

– Other medical conditions

– Immune status of patient

– Was there a prodrome? (early symptoms that might indicate the start of disease)

– When did the rash start?

– Where did the rash start?

– Where has the rash spread to?

– Has there been any change in the rash (appearance, sensation, etc.)

– What has been used to treat the rash?

– Review of systems to rule out inflammatory bowel disease (diarrhea, weight loss, poor appetite, arthritis, etc.)

– Review of systems for SLE (photosensitivity, malar or discoid rash, cytopenias, renal disease, etc.) Differential Diagnosis

Infectious causes

  1. Measles:

– Blanching erythematous maculopapular rash

– Begins in head and neck à spreads centrifugally to trunk and exrtremities

– Associated symptoms: fever, cough, coryza and conjunctivitis

  1. Chickenpox:

– Vesicular lesions on erythematous base

– Lesions appear in crops

– “dew drops on rose petals” appearance

– Lesions are present in different stages: papules, vesicles, crusting

  1. Rubella:

– Rash resembles measles, but patient is not ill looking

– Prominent postauricular, posterior cervical +/- suboccipital adenopathy


– Forschemier spots: small, red spots (petechiae) on soft palate in 20% of rubella patients

  1. Erythema infectiosum (fifth disease)

– human parvovirus B19

– Characteristic rash that resembles “slapped cheeks”

  1. Roseola infantum or exanthema subitum

– Human herpesvirus 6 or 7 infection

– High fever for 3-4 days

– Followed by seizures

– Generalized rash (trunk to extremities, face spared)

  1. 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

  1. Non-polio enteroviruses (coxsackievirus, echovirus)

– Cause variety of different rashes

– Should be included in differential Inflammatory causes Acute rheumatic fever

– Potential sequela of group A streptococcal pharyngitis

– Erythema marginatum

– transient macular lesions with central clearing usually found on extensor surfaces of proximal extremities and trunk

– Subcutaneous nodules over bony prominences

  1. 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

  1. Systemic Lupus Erythromatosis SOAPBRAINMD:

– Serositis (pleuritis or pericarditis)

– Oral (Ulcers)

– Arthritis (Non-erosive, any joint, polyarticular)

– Photosensitive rash

– Blood dyscrasia (anemia, leukopenia, lymphopenia or thrombocytopenia)

– Renal Nephritis


– Immunoreactive (anti-Ds DNA, Anti-Rho, Anti-Sm, Anti-La, antiphospholipid)

– Neurological (Sz, Chorea, Psychosis)

– Malar rash

– Discoid rash

  1. Inflammatory Bowel Disease Associates with two rashes characteristically:

– Erythema Nodosum

– Pyderma Gangrenosum

Procedure for Investigation

Physical Examination

– Vital signs

– General appearance

– energy level,

does the child look sick?

– Lymph node, mucous membranes, conjunctivae and genitalia assessment

– Meningeal signs

– Neurologic evaluation

– Liver and spleen palpation

– Joint examination

– Skin examination

Laboratory Tests

– Complete blood count

– Urinalysis

– Blood cultures

– depending on history of possible exposures

– Serologies

– if indicated

– Fluid from any lesions can be examined

– Unroof vesicles so that base of lesion can be swabbed

– Skin biopsy Source



Leave a Reply

Your email address will not be published. Required fields are marked *