Rashes with Fevers

A mother brings in her 5 year old daughter to the pediatrician

because she had a sudden rash appear on her cheeks that had
spread to her arms and trunk. She also reports that her child
feels very warm. A couple of children in day care had similar
symptoms

Erythema Infectiousus / Fifth disease

Parvo B-19 virus infection spread by respiratory droplets
Prodrome: low grade fever
Slapped cheek erythema maculopapular rash on
extremities
Take caution in patients with sickle cell anemia and pregnant
women
Tx:
Supportive: antihistamine for puritus, and NSAIDS for pain relief
Sickle cell might need transfusion

A 14 year old girl presents to the ED complaining of a painful red

bumps on her shins. She says two weeks ago she had a sore throat
and fever. During triage she is found to have a low grade fever.

Erythema Nodosum
Inflammation of subcutaneous tissue reaction
Red tender nodules
Noninfectious causes
Sarcoidosis
Rheumatic fever
Irritable Bowl Disease
Lupus
Medications: sulfonamides, contraceptive pills

Infectious causes
Group A strep (strep pyogenes)
Tuberculosis
Fungi: Histoplasmosis, coccidioideomycosis

Erythema Marginatum of Rheumatic Fever

An 8 year old boy complains of itching. When his mom

checks his back he has these lesions all over. Reviewing his
chart you see that mom had refused vaccinations when he
was 1 years old and has not gotten any after that.

Varicella/ Chicken Pox

Herpes virus 3
Contagious 24 hours before rash and up until crusting of
lesions
Prodrome: malaise, fever, myalgia
Pruritic lesions appear in crops
Papules, vesicles on erythematous base, crusting
Tx: supportive, can give acyclovir, antihistamine

A young couple brings their newly adopted 2-year-old son to

the pediatrician because he has a temperature of 104
degrees F and a rash. The report that the rash began at his
head and face and spread downward to include the hands
and soles. The mother reports that prior to developing the
rash the child had cough and red eyes

Measles /Rubeola
Paramyxovirus
Prodrome: cough, coryza, conjunctivitis, fever, malaise,
koplik spots
Erythematous maculopapular rash starts on face and spread
down (cephalocaudal). Recovery also starts on face and
spreads down
Tx: supportive
Vitamin A

A 35-year-old woman has been refusing to vaccinate her children due to the
claims that vaccinations may cause autism in children. Her 10-year-old male
child began developing a low-grade fever with a rash that started on his face;
as the rash began to spread to his limbs, it slowly disappeared from his face.
When the child was taken to a clinic, the physician noticed swollen lymph
nodes behind the ears of the child. What is the most likely cause of the rash?

Rubella/ German measles

Rubella virus, togavirus
Prodrome: generalized mild lymphadenopathy and fever
Erythematous, maculopapular rash starts on face and
spreads downwards
Erythema on soft palate (Forschheimer spots)
Congenital rubella
Cataract
Deafness
Patent ductus arteriosis, pulmonary artery hypoplasia/ stenosis
Hepatomegaly
Microcephaly
Blueberry muffin rash (thrombocytopenia)

 A young child is brought to the pediatrician by his mother who reports that
the boy has had a "sore throat" for two weeks and has recently developed
a red flush in the skin with a bright red tongue. He is increasingly agitated
and the rash appears to be spreading to his trunk.

Scarlet Fever
Streptococcus pyogenes
Erythematous tiny papular (sandpaper-like) rash with a
strawberry like tongue
Trunk extremities
Fever, sore throat, nausea
Tx: penicillin

 A 18-year-old female presents to the emergency room via

ambulance after she began experiencing nausea, vomiting,
and diarrhea this morning. Her mother reports that she
began to complain of sudden-onset fever and chills that
started earlier today, as well as the development of a
sunburn-like rash. She had a severe nose bleed a day ago
and used nasal packing in order to stop it. What is the most
likely cause of her symptoms.

Toxic shock syndrome

Staph Aureus preformed TSST-1 toxin
Risk are tampons and nasal packing
Sunburn-like rash desquamation on palms and soles
Symptoms: >102 fever, hypotension, multisystem
involvement
GI (vomiting and diarrhea)
Myalgias (increase creatine kinase)
Renal (BUN and Creatinine high)
Hematologic ( Platelets <100K
Liver (AST and ALT elevated)
CNS: altered mental
Tx: antibiotics that cover staph. IV
fluids and pressors for hypotension

 12-year-old boyscout who returned from a summer camping

trip in Oklahoma one week ago presents with fever, lethargy,
headache, and abdominal pain. Petechial lesions are noted
on the palms of his hands and feet.

Rocky Mountain Spotted Fever

Rickettsia rickettsii transmitted by tick
Petechial rash that spreads centripetal (palms and
soleswrist and ankles trunk)
Flu like symptoms
Tx: doxycycline

 A 16-year-old boy presents to his primary care physician with

fatigue, headache, and arthralgia. The doctor identifies a
ring-shaped lesion on his lower back.

Lyme Disease
Borrelia Burgdorferi, transmitted by Ixodes tick
Erythema chronicum migrans (explanding circle)
Flu like symptoms
Affects heart, joints, and CNS.
Bells palsy
AV block
Tx: oral doxycycline, amoxicillin, or cefuroxime
IV for neurological and cardiac forms ceftriaxone and penicillin

 An 11-year-old boy presents to clinic with a rash on his feet.

He complains of having a fever and feeling "itchy" the day
before and having a sore throat. Physical exam reveals
pharyngeal erythema and a few vesicles. He has a similar
rash on his palms.

Hand Foot and Mouth Disease

Coxsackie Type A
Vesicular rash on palms, soles, and posterior pharynx.
Associated symptoms: fever, sore throat
Tx: supportive

 A 4-year-old child develops a high fever and no other

physical findings. On the third day of illness, the fever rapidly
declines and a spotty, maculopapular rash develops on the
trunk and spreads to the extremities.

Roseola Infantum
Herpes Virus 6
Prodorme: very high fever for about 3 days (risk of febrile
seizures)
Diffuse maculopapular rash after the fever resolves
Tx: Supportive with temperature control

 A 15-year-old female is brought to the emergency room with

high fever and confusion. She complains of chills and
myalgias, and physical examination reveals a petechial rash

Meningococcemia
N. meningitidis
Abrupt onset of fever, chills, malaise and petechial/ purpura rash
Waterhouse-Friderichsen syndrome
Bilateral hemorrhage of adrenal glands
Shock, DIC, coma, death in 6-8 hours

Tx:

IV penicillin, cephalosporins if there is meningitis

IV fluids for blood pressure support
Corticosteroids if adrenals are affected
FFP if DIC

 A 15-year-old boy presents with 3 days of sore throat, fever, cervical

lymphadenopathy, and generalized malaise. On exam he has a
temperature of 102 F, BP 96/50, and a diffuse exudate on both
tonsils. His mother had given him left over amoxicillin because she
had thought he had strep throat He presents with this rash. What is
the most likely cause?

Mononucleosis
EBV
Symptoms: fatigue, malaise, sore throat, cervical
lymphadenopathy, exudate on tonsils, splenomegaly, fever,
chills,
Maculopapular rash with antibiotics
Tx: supportive, counsel on avoiding contact sports

 A 1 year old child is brought because of a fever and large

blisters that break with slight pressure. The skin is
erythematous and desquamating.

Scalded Skin Syndrome

Staph aureus Exfoliative toxin targets desmoglein which is
important in cell to cell adhesion
Prodrome: fever, irritability, and skin tenderness
Erythema flaccid blisters desquamation
+ Nikolsky sign
No mucosal involvement (differentiate from toxic epidermal
necrolysis)
Tx: antibiotics that cover staph. IV fluids to prevent
dehydration.

 A 8 year old child had a cold sore appear on this upper lip
three days ago. The following day his mother also noted a
rash on his palms, shown above.

Erythema Multiforme
Target/bulls eye lesions
Causes
Infections: Herpes Simplex Type 1, mycoplasma pneumoniae
Medication: Beta-lactams, sulfa drugs, phenytoin
Autoimmune disease

Tx:
Antihistamines for pruritus
Acetaminophen for fever
Acyclovir if due to herpes

 A 13-year-old girl re-presents to his

pediatrician with a new onset rash that began
a few days after his initial visit. She initially
presented with complaints of sore throat but
was found to have a negative strep test. Her
mother demanded antibiotics, but since the
doctor refused she have some penicillin she
found left over in the cabinet at home. Shortly
after starting the drug, the girl developed a
fever and a rash seen above. Her skin begins
to slough off, and the rash covers over 30%
of her body. Her oropharynx and corneal
membranes are also affected. You examine
her at the bedside and note a positive
Nikolsky's sign. What is the most likely
diagnosis?

Steven Johnson Syndrome and

Toxic Epidermal Necrolysis
Skin necrosis, bullae formation, sloughing of skin.
Involves 2 or more mucosal surfaces
Steven Johnsons involves <10% of total body surface
Toxin Epidermal necrolysis involves >30%
Death due to secondary infection and sepsis
Tx:
Stopping medications that may have caused it
Supportive: fluids, wound care, pain control, antihistamines for
pruritus, topical steroids to reduce inflammation

 A 4-year-old boy presents to the urgent care center with 3 days of fever to
104 degrees F. On physical exam, he is noted to have conjunctivitis, an
erythematous rash, cervical lymphadenopathy, and swollen hands and feet.
His tongue is noted to be bright red. Labs are remarkable for an absolute
neutrophilic leukocytosis, left-shift, and an elevated ESR. Plateletes are
normal.

Kawasaki
Vasculitis
Symptoms
Fever >104 for 5 days
Truncal rash
Cervical lymph node >1.5cm
Bilateral nonexudative conjunctivitis
Mucositis, strawberry tongue, cracked lips
Hand and foot edema and desquamation

Tx:IVIG and aspirin

Affects coronary vessels leading to aneurysm