THE PATIENT PRESENTS WITH

1. Fever or rash 2. Heart, lung or ENT problems 3. Gut or liver problems 4. Haematuria or proteinuria 5. Neurological problems 6. Musculoskeletal problems 7. Pallor, bleeding, splenomegaly or lymphadenopathy 8. Short stature or developmental delay 9. Neonatal problems

3 9 19 27 31 37 41 49 55

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Fever or rash Objectives At the end of this chapter. any ill child must have an assessment of the airway. self-limiting. • A painful limb: suggests infection of the bones or joints. The latter has the potential to deteriorate rapidly so it is essential that it is identified as early as possible. Learn a systematic approach to a child with petechial rash. Assume sepsis in all febrile infants aged <3 months until proved otherwise.1). Are there any localizing symptoms? An infection in certain systems will advertise itself: • Cough or coryza: suggest respiratory tract infection. Most of the causes are due to benign. • Vomiting and diarrhoea: suggest gastrointestinal tract infection. and of the vital signs. meningitis and septic arthritis can all be revealed on examination 3 Ch001-M3462.7): • Poor peripheral perfusion. Younger children (<2 years of age) might not localize symptoms and fever might be the only symptom. However. photophobia and neck pain: suggest meningism. breathing and circulation. although vomiting alone is non-specific. Electronic tympanic membrane thermometers correlate moderately well with rectal temperature and are adequate for most practical purposes. • Headache. 1 THE FEBRILE CHILD Fever is a common presenting symptom in children and can be a major challenge to paediatricians. Has there been recent foreign travel? Malaria or typhoid can be overlooked if recent travel abroad is not disclosed in the history. Identify the warning signs in a child with fever and rash. pneumonia. • Lethargy or irritability. • Lower abdominal pain: suggests urine infection but lobar pneumonia can also present this way. playing and communicative child is unlikely to have sepsis. 1. 1.indd 3 3/18/2008 12:12:19 PM . malaria. Clues to serious sepsis include (see Fig. otitis media. you should be able to • • • • Assess a child with fever. Understand the common types of rash in children. viral infections but skill is needed to distinguish these from serious infection (Fig. typhoid and autoimmune non-infectious disorders. History How long has the child been febrile? A duration of more than a week or two suggests diseases such as tuberculosis (TB). Examination Is the child systemically unwell? The active. Are there local signs of infection? Tonsillitis. Fever is defined as a central temperature of greater than 38°C. • Persistent tachycardia.

Common causes of a fever Minor illnesses Upper respiratory infection Non-specific viral infections and rashes Gastroenteritis without dehydration Major illnesses Meningitis Pneumonia A seriously ill child might initially have normal blood inflammatory markers. throat swab and cerebrospinal fluid. These include: • Markers of inflammation: white cell count (raised or low in overwhelming sepsis). • Imaging: a chest X-ray (CXR) should be considered if there is any suspicion of lower respiratory tract infection. lumbar puncture.2). Treating the fever with antipyretics might reduce febrile convulsions. Most are infectious and 40–60% will resolve without diagnosis. differential (neutrophil predominance in bacterial infection) and C-reactive protein. (Fig. treatment can be tailored when the results are back. CRP. Look for a bulging fontanelle in meningitis. they cannot rule out serious infection. These include: blood culture. full blood count (FBC). urine sampling and CXR. antibiotics are started before the results of diagnostic testing because quickly ruling out serious infection is often impossible. Lethargy. In the very young. no investigation is required. Polymerase chain reaction (PCR) is becoming increasingly useful as it provides high sensitivity and specificity. • A ‘septic screen’. 1.2 Fever: important sites of local bacterial infection. 1. urine for microscopy and culture. These are useful if there is uncertainty in diagnosis or for serial measurement of a septic Pyrexia of unknown origin (PUO) The designation PUO should be reserved for a child with a documented protracted fever (more than 7 days) and no diagnosis despite initial investigation (Fig. Particular 4 Ch001-M3462. 1. Management If a benign viral infection is suspected then only symptomatic therapy is needed. or those who look ill. Low capillary refill. Elevated or low temperature suggests Serious Sepsis. a rash might be diagnostic. however.indd 4 3/18/2008 12:12:19 PM . Investigations In a well child in whom a confident clinical diagnosis has been possible. Fig. Urinary tract infection Septicaemia Fig. It is frequently misapplied to any child presenting with a fever of which the cause is not immediately obvious.3). certain investigations are appropriate in any ill febrile child.1 Common causes of a fever. Neutropenia or neutrophilia. However.Fever or rash child. Septic arthritis Aide-mémoire to identify serious sepsis ILLNESS—Irritability. 1. infants suspected of severe infection without localizing signs on examination are investigated with a standard battery of investigations before starting antibiotic therapy. Meningitis Otitis media Acute tonsillitis Pneumonia Urinary tract infection • Samples for microbiological examination: blood cultures.

Arthropathy. viral exanthems. thickness. observing the morphology. • Vesicles. or might not. Palpation Feel the rash for scale.The child with a rash 1 Type Infective Cause Pyelonephritis Osteomyelitis Abscesses Endocarditis Tuberculosis Typhoid CMV HIV Hepatitis Malaria Kawasaki disease Rheumatoid arthritis Crohn disease Leukaemia. sore throat. Causes of a rash The main causative categories are shown in Fig. Distribution The distribution is important (Fig. Investigations Investigations are rarely required but might include skin scrapings for fungi or scabies.g. site of onset. It can be local or generalized (flexor surfaces: eczema. 1. extensor surfaces: Henoch–Schönlein purpura (HSP) or psoriasis) or might involve mucous membranes (measles. Fig. Mucous membranes.indd 5 3/18/2008 12:12:19 PM . upper respiratory tract infection)? • Is there any family history (e. Stevens–Johnson syndrome). Kawasaki disease. scabies)? Has there been any recent drug ingestion or exposure to provocative agents (e. psoriasis)? It is important to note the distribution as well as the morphology of a rash.g. Arrangement Are the lesions scattered diffusely. lymphoma Only recorded by patient Examination Check for non-dermatological features such as: • • • • • Fever. Kawasaki disease. An exact diagnosis is often not possible but a few rashes are associated with serious systemic disease. sunlight. eczema. allergens. • Petechiae. papules or nodules. 5 Ch001-M3462.5. juvenile chronic arthritis). Does it come and go (e.g. patterns of fever and response to treatment can be helpful in making important diagnosis (e. dry skin suggests eczema. There might be: • Macules. atopy. Inflammatory Describe the rash in ‘dermatological language’. texture and temperature. food. 1. detergents)? • Are any other family members or contacts affected (e. Splenomegaly. purpura or ecchymoses.g.4). Careful clinical history and examination are again essential and investigation is reserved only for certain cases.g. History The history of a rash should ascertain the following: • • • • Duration.3 Causes of pyrexia of unknown origin (PUO). 1.g. pustules or bullae.g. well circumscribed or confluent? THE CHILD WITH A RASH Children often present with a rash that might. urticaria)? Does the rash ‘itch’ (e. infestations. size and colour of the lesions. Malignancy Factitious fever Morphology Describe the shape. evolution and spread. Lymphadenopathy. see Chapter 10)? • Are there any other associated symptoms (e. arrangement and distribution of the lesions. be associated with systemic signs.

• Idiopathic thrombocytopenic purpura: the child looks well but might have petechial rash with. Causes of a rash Vesicular rash Type Infection Cause Viral Toxin related Streptococcal Meningococcal Scabies Eczema Vasculitis Drug-related Urticaria Bleeding disorders Common causes of vesicular rash are: • Chickenpox: successive crops of papulovesicles on an erythematous base. generalized rash.indd 6 3/18/2008 12:12:20 PM . • Glandular fever: symptoms include malaise. Just before the rash appears. After 3 days of sustained fever. • Roseola infantum: occurs in infants under 3 years. • Enteroviral infection: causes a generalized. 1. The rash tends to coalesce. Scalp and behind ears Seborrhoeic dermatitis Eczema Psoriasis Fungal Mucous membranes Measles Kawasaki disease Stevens−Johnson syndrome Herpes Trunk Viral exanthems Molluscum contagiosum Flexor surfaces Eczema Web spaces Scabies Nails Fungal infections Psoriasis Extensor surfaces Psoriasis Henoch−Schönlein purpura Shin Erythema nodosum Fig. haemorrhagic rash and urticarial rash. • Kawasaki disease: causes a protracted fever. a pink morbilliform (measles-like) eruption appears as the temperature subsides.4 Distribution of rashes. • Acute leukaemia: look for pallor and hepatosplenomegaly. The mucous membranes are involved. • Eczema herpeticum: exacerbation of eczema with vesicular spots caused by a herpes infection. It is caused by human herpesvirus (HHV)-6 or HHV-7. nose bleeds. Fig. Lymphadenopathy and splenomegaly are commonly found. • Rubella: discrete.5 Causes of a rash. Maculopapular rash This is most likely to be caused by a viral exanthem but might be a drug-induced eruption. The rash starts on the face and can include a ‘strawberry’ tongue. Diagnostic features of the more common generalized rashes The common generalized rashes are: maculopapular rash. Common diagnostic features are: 6 Ch001-M3462. • Scarlet fever: causes fever and sore throat. Common diagnostic features are: • Meningococcal septicaemia: petechial or purpuric rash (might be preceded by maculopapular rash). Lesions are classified by size: • Petechiae (smallest).Fever or rash • Measles: prodrome of fever. Lesions present at different stages. fever and exudative tonsillitis. vesicular rash. the vesicles become encrusted. Koplik’s spots appear in the mouth. 1. Occipital and cervical lymphadenopathy might precede the rash. or without. pink macular rash starting on the scalp and face. red lips. Infestations Dermatitis Allergy Haematological Haemorrhagic rash Due to extravasated blood these lesions do not blanch on pressure. coryza and cough. pleomorphic rash and produces a mild fever. lymphadenopathy and conjunctival inflammation. • Ecchymoses (largest). • Purpura.

• Mechanical causes: trauma. appears rapidly and fades. 7 Ch001-M3462.indd 7 3/18/2008 12:12:20 PM . it can recur.7) • Unwell child: tachycardia. mycoplasma or Epstein–Barr virus) and drugs. e. penicillin: note that <10% of penicillin allergies are unsubstantiated. e. administration of a third generation cephalosporin (cefotaxime 50 mg/kg or ceftriaxone 80 mg/kg). C reactive protein. cows’ milk. • Infections.6 shows an algorithm that is useful in identifying serious sepsis. coagulation screen.g. Urticarial rash Urticaria (hives). immediate administration of fluid resuscitation. liver function and throat swab. • Purpura >2 mm and spreading. The severe form with mucous membrane involvement is Stevens–Johnson syndrome.g. e. tachypnoea. Take care to think of child abuse in traumatic bruising. 1. papules and bullae. meningococcal PCR. Causes include infections (most commonly herpes simplex. itchy rash characterized by raised weals. Indicators of serious sepsis (see Fig. lethargy. Non-blanching or rapidly spreading rash suggests meningococcal sepsis. animal hair. plants. e. Two other distinctive rashes that occur in childhood and require special consideration are erythema multiforme and erythema nodosum. • Investigations: full blood count.g.The child with fever and petechial rash • Henoch–Schönlein purpura: distribution is usually on the legs and buttocks. a transient. symmetrical rash characterized by annular target (iris) lesions and various other lesions including macules. eggs. acute leukaemia. grasses. high CRP. blood culture. Figure 1. Erythema multiforme A distinctive. tender. • Abnormal blood results WCC <5 or >20. • Bleeding disorders : haemophilia. nodular lesions usually occur on the shins. Von Willebrand disease and Ehlers–Danlos usually present with easy bruising and prolonged bleeding following trivial trauma. poor capillary refill. non-accidental injury. viral: this is the most common and is often self-limiting. Mostly it is idiopathic and self limiting. early senior intensive care input.g. However there are many other important causes of fever and petechiae including: • Infections: viral infections (enteroviruses and influenza). bacteraemia with Streptococcus pneumoniae and Haemophilus influenzae. • Contact allergy. obtaining good venous access. meningococcal disease. cold extremities. 1 THE CHILD WITH FEVER AND PETECHIAL RASH The most important differential diagnosis in this common scenario is serious sepsis especially meningococcal disease which requires immediate treatment. renal function. • Drug allergy. shellfish. forceful coughing/ vomiting with petechiae seen in the distribution of the SVC—face and neck. Management of early meningococcal disease/septicaemia Principles of management are: • Oxygen. • Other diseases: Henoch–Schönlein purpura. irritability. Arthralgia and abdominal pain might be present. neutrophilia or neutropenia. ITP. Erythema nodosum Red. Causes include: • Food allergy. The majority of children presenting with fever and petechiae do not have serious sepsis. Important causes include streptococcal infections and TB.

8 Ch001-M3462. CRP. Fever and petechial rash Purpura (>2mm or spreading) Yes Treat as serious sepsis [meningoccocal disease] Yes No Unwell: tachycardia.Fever or rash Fig. poor capillary refill No Treat the cause Yes Mechanical cause? (SVC distribution. Fig. check blood count. if bloods normal and remains well after 6 hours observation. consider discharge Worrying signs of serious bacterial sepsis All children less than 3 months old Bulging fontanelle White cell count greater than 20 109/L or less than 4 109/L Presence of shock Decreased conscious level or lethargy Persistent tachycardia Apnoea Non-blanching rash Further reading Brogan PR.7 Worrying signs of serious bacterial sepsis. 333:685–690. h/o cough / vomiting / local trauma) No Admit and observe. Raffles A. tachypnoea. PCR Yes Rash progressing? No Treat the cause Yes Abnormal blood results No Senior review. 1. blood culture. British Medical Journal 2006. Meningococcal disease and its management in children. 1. Archives of Disease in Childhood 2000. cold extremities.6 Algorithm for clinical decision making in child presenting with fever and petechiae. 83: 506–507. Hart CA.indd 8 3/18/2008 12:12:20 PM . coagulation screen. The management of fever and petechiae: making sense of rash decisions. Thompson APJ.

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