PEDIATRICS PART 1: FEVER AND RASH
| PEDIATRIC FEVER —Lance Brown, MD, MPH, Associate Professor of Emergency Medicine and Pediatrics and Chief,
Division of Pediatric Emergency Medicine, Loma Linda University Medical Center and Children’s Hospital, Loma Linda,
California
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| Top 10 diagnoses that prompt lawsuits: meningitis ranked first, appendicitis ranked second, and pneumonia ranked
tenth; remainder of top 10 not accompanied by fever; meningitis most common and pneumonia third most common in children
0 to 2 yr of age; meningitis and appendicitis second and third most common, respectively, in chidren 3 to 5 yr of age; appendicitis
and meningitis second and third most common in children 6 to 11 yr of age; in children ≥12 yr of age, appendicitis second
most common
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| Meningitis: 1100 infants and children studied from 1954 to 1976; 98.5% manifested meningeal signs, ie, bulging fontanelle,
nuchal rigidity, Kernig’s sign or Brudzinski’s sign; 16 did not have meningeal signs (5 lethargic or irritable, 2 comatose, 5
had petechiae, 4 got antibiotics and lumbar puncture [LP]); except for children <2 mo of age, speaker not worried about
missing meningitis because those who have it appear sick
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| Appendicitis: 1996 study of 1100 children 2 to 12 yr of age complaining of nontraumatic acute abdominal pain; among
various diagnoses, appendicitis accounted for 0.9%; children express their world through their bellies, hence belly
pain; do not need high index of suspicion
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 | Children ≤2 mo of age: appendicitis presents with lethargy, vomiting, diarrhea, fever, irritability, grunting, cough, rhinitis
(norm for children), hip pain or limp, abdominal distention, abdominal rigidity, rectal mass; diffuse abdominal tenderness
seen in 55% to 92%; localized abdominal tenderness seen in <50%; abdominal rigidity in 23%; speaker opines
standard of care in children <1 yr of age is to find appendicitis after it perforates
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| Complete blood count (CBC): not helpful unless patient neutropenic or has leukemia
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| Missed appendicitis: mostly in younger patients; “and they’re less likely to have right lower quadrant pain because they don’t
localize it”; if unsure of diagnosis, document “unspecified”
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| Conclusion: appendicitis remains challenging diagnosis; not making diagnosis until perforation probably standard of care
for little children; testing can be misleading or unhelpful
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| Pneumonia: any critically ill child can develop pneumonia, particularly chronically ill child; if patient with abdominal
pain has history of cough, order chest x-ray (retrocardiac infiltrate causes severe abdominal pain and ileus; appendicitis
does not have cough); if child with retrocardiac infiltrate misdiagnosed with appendicitis, and surgeon removes normal
appendix, but antibiotics not administered, child may die of sepsis
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| Speaker’s recommendations: share diagnostic ambiguity with family; give nonspecific but accurate diagnoses such
as abdominal pain, vomiting, or cough, rather than specific wrong diagnosis; perform repeat examinations during emergency
department (ED) stay and document; arrange follow-up examinations for unclear cases, even if patient must see
different physician next day; obtain appropriate consultation
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| Approach to well-appearing child with fever
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| Main points: vaccinations have changed overall approach to pediatric fever; traditional decision nodes have faded in utility;
age group of greatest interest now infants ≤2 mo of age; viral testing and treatment newer area of controversy;
urine testing rising in importance and understanding
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| Vaccinations: have immunized many organisms out of existence in children, leaving sepsis and diarrhea; Haemophilus
influenza type b (Hib) vaccine reduced incidence of epiglottitis in children by 99%; pneumococcal conjugate vaccine
(Prevnar) caused reduced invasive Streptococcus pneumoniae by 80%
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| Bacteremia: can get bacteria in blood from brushing teeth or having hard bowel movement; risk for occult bacteremia
<1% in era of pneumococcal vaccine; contaminants seen in laboratory studies more commonly than disease; decision
nodes—data points that reliably differentiate one group from another; traditional decision nodes (eg, toxic vs nontoxic,
white blood cell [WBC] count, and response to antipyretics) have faded in utility; better to use well-appearing vs
not well-appearing
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| Infants <2 mo of age: most difficult to assess; do not have relevant vaccinations; have vague and common illness manifestations,
eg, poor tone, poor feeding, mottled skin, improper sleep, decreased urination; have different organisms (eg,
Escherichia coli, Klebsiella) and immature immune system; >85% of children with fever in this age group have no
serious bacterial infection
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| Child with history of fever but afebrile in ED: test urine
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| Viral testing: many questions persist, eg, if infant positive on viral testing, does he or she need sepsis work-up? positive
viral test decreases likelihood of bacterial infection but does not rule it out
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| Urine testing: look for occult pyelonephritis; amoxicillin treats urinary tract infections (UTIs); do not use bagged urine to
test for infection
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| Speaker’s recommendations: for well-appearing febrile children; 0 to 28 days of age—perform full septic work-up, including
LP, intravenous (IV) antibiotics (ampicillin and cefotaxime), and admit; 29 to 56 days of age—full sepsis
work-up; if everything negative, give ceftriaxone, send home, and follow up in 1 day; older children—obtain catheterized
urine in circumcised boys 57 days to 6 mo of age, uncircumcised boys 57 days to 12 mo, and in girls 57 days to
2 yr or until potty trained
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| PEDIATRIC RASHES —Pamela L. Dyne, MD, Associate Professor of Medicine/Emergency Medicine, David Geffen School
of Medicine at the University of California, Los Angeles, and Olive View-UCLA Medical Center, Department of Emergency
Medicine
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| Objectives: learn terminology that consultants use so can communicate with them; learn differential diagnosis for categories
of rash in children, ie, maculopapular, petechial, urticarial, and vesicular or bullous
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| Terminology: macule—nonpalpable spot, usually red; patch—macule >1 cm; papule—palpable; can feel depth on
palpation; usually red; <1 cm; plaque—papule >1 cm; nodule—palpable bump deeper in skin; does not have to be red;
maculopapular—combination of macules and papules; seen with viral illnesses and allergic reactions; vesicle—
blister; bulla—blister >1 cm; pustule—pus-filled blister; colored fluid; wheal—palpable; edges well demarcated;
usually red and blanching (like hives); purpura—nonblanching red or purple spots; may or may not be palpable
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| Case 1: 11-mo-old girl, otherwise healthy, presents with history of seizure; patient had fever for 1 day; appears postictal;
temperature 39.5°C; examination otherwise unremarkable; patient had febrile seizure; likely she has viral syndrome; patient
sent home but returned 2 days later with rash (fever resolved)
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| Description of rash: red with some discrete areas and some more confluent areas; some areas palpable and some areas not
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| Discussion: patient has maculopapular rash; diagnosis roseola; common; cannot be diagnosed when patient presents with
fever; must wait until rash appears; caused by human herpesvirus 6; occurs in younger children (3 mo to 4 yr); transmitted
by respiratory secretions; not particularly dangerous; by time patients present with rash, they are well; rash resolves
spontaneously after 2 days
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| Case 2: 18-yr-old girl returns home from college for Thanksgiving break complaining of sore throat and fever for 1 wk;
has exudative pharyngitis and lymphadenopathy; diagnosed by radiologist father as strep throat; started on amoxicillin;
patient gets rash; has areas of confluence and areas of more discrete bumps that are red; some blanching; has areas of
palpable and nonpalpable rash (maculopapular)
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| Discussion: patient had mononucleosis; viral illness caused by Epstein-Barr virus (EBV) or cytomegalovirus (CMV); has
characteristic syndrome of malaise, fever, pharyngitis, and lymphadenopathy; check for splenomegaly
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| Rubella: mild viral illness characterized by tender lymph nodes in postauricular and suboccipital area and rash lasting ≈3
days; still seen, although most people immunized; benign illness, except when it causes congenital rubella syndrome
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| Fifth disease (erythema infectiosum): presents with classic “slapped-cheeks” rash; caused by parvovirus B19; occurs
most commonly in children 5 to 14 yr of age; spread by respiratory secretions; light red lacy rash on extremities that
comes and goes with physical exertion; need some follow-up because patient can develop aplastic anemia
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| Measles: patients present ill-appearing with red eyes, maculopapular rash all over, and Koplik’s spots in mouth (pathognomonic
for measles); fever, cough, coryza, and conjunctivitis for ≈2 days, followed by rash; rash starts at hairline and
progresses down body, involving palms and soles; more significant illnesses tend to involve palms and soles; rash tends
to be concentrated on upper torso and back; lasts ≈7 days; may have peeling; may need admission for supportive care;
spread by respiratory droplets; modified measles—occurs after immunization; looks same but has longer prodrome and
milder symptoms; diagnosed by history of immunization; atypical measles—occurs as result of incomplete immunity in
patients who received killed vaccine and are then exposed to wild virus; no prodrome; rash spreads from peripheral to
central; rash can be “just about anything,” including petechiae
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| Differential diagnosis for viral maculopapular rashes: measles (patients look sick); rubella; roseola (has fever,
then rash, then rash resolution); nonspecific viral; early varicella (chickenpox; can be maculopapular before vesicles
start); early coxsackie (sometimes looks like red spots before vesicles start)
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| Case 3: immunized otherwise healthy 3-yr-old presents with fever, sore throat, and rash for 3 days; has swollen lymph
nodes and exudative pharyngitis; tongue looks like strawberry (red with white spots); red rash confluent in groin and
armpit areas, blanching, and itchy
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| Scarlet fever: classic morbilliform rash has tiny, barely palpable, red bumps confluent in skin folds and blanching; feels
like sandpaper; caused by group A β-hemolytic Streptococcus; typically occurs in school-age children; treat with supportive
care and antibiotics (like strep throat); usually goes away in 4 to 5 days; warn parents that patient’s skin will peel
in areas of rash
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| Case 3 progression: patient returned 5 days later with continued high fever to 40°C despite antibiotics; no desquamation
in areas of rash as expected but had peeling around nails (periungual desquamation); patient diagnosed with Kawasaki disease
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| Kawasaki disease: idiopathic; diagnostic criteria include child <5 yr of age with high spiking temperatures to ≥40°C for
>5 days, and 4 of following, 1) extremity changes (fingers and hands can be red and swollen; can get periungual desquamation
starting at 1 wk), 2) any type of rash that is not vesicular, 3) eye findings (painless conjunctivitis without exudate),
4) oral changes (eg, strawberry tongue, cracked lips, red throat), 5) enlarged lymph nodes (usually unilateral with one of
them >1.5 cm); 20% get cardiac complications (eg, coronary artery aneurysms; get pediatric cardiology involved); admit
for echocardiography and intravenous immunoglobulin (IVIG) and salicylates to prevent cardiac complications
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| Differential diagnosis for bacterial maculopapular rashes
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| Staphylococcal scalded skin syndrome: occurs in babies; caused by toxin from Staphylococcus aureus; erythroderma all
over body, with large bullae appearing 2 days later; treat like burn victim; admit and manage with IV antibiotics and
fluids
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| Toxic shock: caused by toxin from S aureus; can have fever, nausea, vomiting, and malaise; can be shocky; can have diffuse,
nonspecific rash that may include hands and feet; skin may peel; requires hospital admission, IV antibiotics, fluids,
and aggressive supportive care; look for and remove foreign body or abscess; streptococcal version associated with
toxic shock and organ failure (may or may not have rash); caused by group A streptococci
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| Erythema multiforme: target lesions with areas of central clearing in area of redness; hypersensitivity reaction to drug or
infection
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| Case 4: 12-yr-old boy with history of camping 2 weeks ago; presents with fever, headache, irritability, myalgias for 2
days, and rash on arms and legs for 1 day; has petechial lesions (ie, dark, red spots that do not blanch)
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| Rocky mountain spotted fever: caused by Rickettsia rickettsii; transmitted by bite of infected tick; invades blood
vessels and causes vasculitis; 60% of patients have history of tick bite; treat with tetracycline; occurs in central and Atlantic
states
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| Henoch-Schönlein purpura (HSP): nonblanching purpura on lower extremities look like bruises; immune-mediated;
anaphylactoid reaction to infections, anemia, medications, or toxins; body’s immune response goes wild; showers
of immune complexes distribute throughout body, causing microhemorrhages at sites of deposition; can get abdominal
pain, migratory arthritis, microscopic hematuria, and petechial rash; patients generally do well; can develop renal insufficiency
and hypertension if kidneys infected; abdominal and joint pain biggest problems; give acetaminophen and supportive
care; check renal function (should be followed by pediatrician); patients generally do not need to be admitted
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| Meningococcemia: worst cause of petechial rashes; patients ill-appearing; onset acute
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| Take-home points: rashes usually part of constellation of symptoms; keep differential diagnosis for each type of rash in
mind; maculopapular category—is it bacterial? (those are cases that require treatment); clues include involvement of
hands and feet, and desquamation phase; petechial category—think meningococcemia; do not want to miss it; “why are
they bleeding into their skin?” urticarial category—does patient have complicating anaphylactoid reaction? does it
need immediate treatment? vesicular or bullous—wear gloves
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Educational Objectives
| The goal of this program is to educate the listener about pediatric fever and rash. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. List the most common diagnoses involving fever that prompt lawsuits.
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| 2. Describe the diagnosis and management of appendicitis and pneumonia in pediatric patients.
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| 3. Discuss the management of the well-appearing child with fever in the emergency department.
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| 4. List the terminology used by dermatologists to describe the different types of rashes.
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| 5. Describe 3 cases that illustrate 3 classifications of rashes.
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Discussed on This Program
Acetaminophen (N -acetyl-P -aminophenol; APAP) [many trade names]
Amoxicillin [Amoxil, Trimox]
Ceftriaxone sodium [Rocephin] Haemophilus b conjugate vaccine [ActHIB, HibTITER, Liquid PedvaxHIB]
Ibuprofen [Motrin, many others]
Pneumococcal 7-valent conjugate vaccine (diphtheria CRM197 protein) [Prevnar]
Tetracycline HCl [Sumycin]
Programs of Related Interest
Clarke JT et al: Dermatology update. Audio-Digest Family Practice 53:40(Oct 28), 2005; Jacobs RF, Shah SS:
Perspectives on fever. Audio-Digest Pediatrics 51:04(Feb 21), 2005; Satkowiak L: High risk pediatrics. Audio-Digest
Emergency Medicine 21:19(Oct 7), 2004; Sharieff G, King C: Pediatric update. Audio-Digest Emergency Medicine
21:09(May 7), 2004; Wilde JA, Berkowitz C: Fever in children. Audio-Digest Family Practice 52:34(Sep 14), 2004;
Zuber TJ et al: Topics in dermatology. Audio-Digest Family Practice 52:21(Jun 7), 2004.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Andreoni M et al: Primary human herpesvirus 8 infection in immunocompetent children. JAMA 287:1295, 2002; Dueholm
S et al: Laboratory aid in the diagnosis of acute appendicitis. A blinded, prospective trial concerning diagnostic
value of leukocyte count, neutrophil differential count, and C-reactive protein. Dis Colon Rectum 32:855, 1989; Farizo
KM et al: Pediatric emergency room visits: a risk factor for acquiring measles. Pediatrics 87:74, 1991; Geiseler PJ et
al: Bacterial meningitis without clinical signs of meningeal irritation. South Med J 75:448, 1982; Lee GM et al: Risk of
bacteremia for febrile young children in the post-Haemophilus influenzae type b era. Arch Pediatr Adolesc Med 152:624,
1998; Levine DA et al: Risk of serious bacterial infection in young febrile infants with respiratory syncytial virus infections.
Pediatrics 113:1728, 2004; McCarthy PL et al: Bacteremia in children: an outpatient clinical review. Pediatrics
57:861, 1976; Nance ML et al: Appendicitis in the young child: a continuing diagnostic challenge. Pediatr Emerg Care
16:160, 2000; Patt HA et al: Diagnosis and management of suspected cases of bioterrorism: a pediatric perspective. Pediatrics
109:685, 2002; Reynolds SL: Missed appendicitis in a pediatric emergency department. Pediatr Emerg Care 9:1,
1993; Rothrock SG et al: Acute appendicitis in children: emergency department diagnosis and management. Ann
Emerg Med 36:39, 2000; Rothrock SG et al: Clinical features of misdiagnosed appendicitis in children. Ann Emerg
Med 20:45, 1991; Scholer SJ et al: Clinical outcomes of children with acute abdominal pain. Pediatrics 98:680, 1996;
Selbst SM et al: Epidemiology and etiology of malpractice lawsuits involving children in US emergency departments and
urgent care centers. Pediatr Emerg Care 21:165, 2005; Shaw KN et al: Prevalence of urinary tract infection in febrile
young children in the emergency department. Pediatrics 102:e16, 1998; Shaw KN et al: Screening for urinary tract infection
in infants in the emergency department: which test is best? Pediatrics 101:E1, 1998; Sonmez K et al: Conservative
treatment for small intestinal intussusception associated with Henoch-Schönlein’s purpura. Surg Today 32:1031, 2002;
Stoll ML et al: Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate
vaccine: a study from a Children’s Hospital Emergency Department and Urgent Care Center. Arch Pediatr Adolesc
Med 158:671, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the speakers
reported no conflict.
Dr. Brown was recorded at High Risk Emergency Medicine, held in San Francisco, May 11-13, 2005, and sponsored by
the University of California, San Francisco, School of Medicine, Department of Emergency Medicine, and Division of
Emergency Services, San Francisco General Hospital; Dr. Dyne at Advances in Emergency Medicine and Primary Care,
held in Coronado, California, April 22-24, 2005, and sponsored by Olive View Medical Center Department of Emergency
Medicine, the David Geffen School of Medicine at the University of California, Los Angeles, and the American College of
Emergency Physicians, State Chapter of California, Inc. The Audio-Digest Foundation thanks the speakers and the sponsors
for their cooperation in the production of this program.
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