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Paediatrics > The Febrile Child with a Rash > Flashcards

The Febrile Child with a Rash Flashcards

1
Q

What are the subsets of fever in a child?

A
  • Recurrent infection
  • Pyrexia of unknown origin
  • Fever with swelling in the neck
  • Acute fever
  • Fever and rash
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2
Q

What are the causes of recurrent infection?

A
  • HIV infection and AIDS
  • Hyposlenism and splenectomy
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3
Q

What are some causes of pyrexia of unknown origin?

A
  • Infective endocarditis
  • Osteomyelitis
  • Collagen vascular disease
  • Inflammatory bowel disease
  • Neoplastic disease
  • Factitious fever
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4
Q

What are some causes of fever with swelling in the neck?

A
  • Cervical adenitis
  • Infectious mononucleosis
  • Mumps
  • Thyroiditis (often no fever)
  • Mastoiditis
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5
Q

What are some causes of acute fever?

A
  • Upper respiratory tract infection
  • Tonsilitis
  • Otitis media
  • Nonspecific viral infections
  • Pneumonia
  • Meningitis
  • UTI
  • Septic arthritis
  • Non-infectious
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6
Q

What are some causes of fever and rash?

A
  • Measles
  • Rubella
  • Roseola
  • Scarlet fever
  • Fifth disease
  • Hand, foot and mouth disease
  • Chicken pox
  • Meningococcaemia
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7
Q

What are the three broad causes of fever?

A
  • Infection
  • Chronic inflammation
  • Immune response
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8
Q

What classifies as a fever?

A

Oral temperature >37.5 degrees C (>37.8 in adults)

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9
Q

When are investigations for a fever always indicated?

A

When the child is <8 weeks old

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10
Q

Which investigations are relevant for a fever and what would they show if they highlighted cause of fever?

A
  • FBC - raised WCC with increased neutrophil count = bacterial infection
  • Throat swab - bacterial cultures (beta-haemolytic strep treat with penicillin)
  • Blood cultures - culture of single organism indicates septicaemia, multiple organisms indicates contamination
  • Lumbar puncture
  • Chest x-ray - consolidation indicates pneumonia
  • Urinalysis and culture - >10^5 cell colonies with >50 WCC, red cells and protein indicates infection
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11
Q

When should a fever be treated?

A

When it is >38.5 degrees, or below that level if the child is uncomfortable

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12
Q

How can fever be brought down?

A
  • Undress the child
  • Antipyretics eg. paracetamol and ibuprofen
  • Sponging or tepid baths with lukewarm water to allow vasodilation
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13
Q

Why should aspirin not be given to children?

A

Because of associations with the development of severe liver disease (Reye’s syndrome)

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14
Q

What are the signs of tonsillitis on throat swab?

A

Tonsillar redness +- exudate, cervical lymphadenopathy

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15
Q

What are the signs of otitis media on otoscopy?

A

Bulging and red tympanic membrane

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16
Q

Which causes of fever cause macular and maculopapular rashes?

A
  • Measles
  • Rubella
  • Roseola
  • Scarlet fever
  • Fifth disease
  • Non-specific viral illnesses
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17
Q

Which causes of fever cause vesicular rashes?

A
  • Chicken pox
  • Hand, foot and mouth disease
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18
Q

Which causes of fever cause purpuric rashes?

A

Meningococcaemia

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19
Q

What are the main complications of measles?

A
  • Otitis media (most common)
  • Pneumonia, pneumonitis and tracheobronchitis
  • Convulsions, encephalitis and blindness
  • Subacute sclerosing panencephalitis (rare)
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20
Q

What are the symptoms of measles?

A
  • Fever
  • Cough
  • Coryza
  • Conjunctivitis
  • Maculopapular rash with or without Koplik’s spots
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21
Q

What should be done if measles is suspected?

A

The local Health Protection Team (HPT) should be notified to confirm the clinical diagnosis, as measles is a notifiable disease

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22
Q

What is the management of measles?

A
  • Rest, adequate fluids, paracetamol/ ibuprofen for symptomatic relief
  • Vitamin A for all children <2
  • Isolate for 4 days after development of the rash and avoid contact with susceptible people
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23
Q

When is admission of a measles patient necessary?

A

If they develop a serious complication of measles:
- Pneumonia
- Neurological problems eg. febrile convulsions or encephalitis

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24
Q

What is the incubation period for measles?

A

10-14 days

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25
Q

What is the transmission of measles?

A

Respiratory droplets

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26
Q

When is measles infective?

A

From the prodrome until 4 days after the rash starts

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27
Q

What is the prodromal phase of measles?

A
  • Irritable
  • Conjunctivitis
  • Fever
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28
Q

Where does the measles rash usually start?

A

Behind the ears

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29
Q

What should be offered if a non-immunized child comes into contact with measles?

A

The MMR vaccine within 72 hours

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30
Q

How is diagnosis of measles primarily achieved?

A
  • Measles-specific IgM and IgG serology (most sensitive 3-14 days after onset of rash)
  • Measles RNA detection by PCR (most sensitive 1-3 days after rash onset)
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31
Q

What type of vaccine is the MMR?

A

Live attenuated

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32
Q

In which children is the MMR vaccine contraindicated?

A

Children with immunosuppression (all live attenuated vaccines are contraindicated)

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33
Q

What is the duration of the rash in measles?

A

5 days

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34
Q

What causes rubella?

A

Viral infection caused by the togavirus

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35
Q

What is the risk if rubella is contracted during pregnancy?

A

Congenital rubella syndrome

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36
Q

When are rubella outbreaks more common?

A

Around winter and spring

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37
Q

What is the incubation period of rubella?

A

14-21 days

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38
Q

What is the transmission of rubella?

A

Respiratory droplets or aerosols

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39
Q

When is the MMR vaccine given?

A

12 months

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40
Q

What are the symptoms of rubella?

A
  • Fever
  • Coryza
  • Arthralgia
  • Maculopapular rash beginning on the face and moving down the trunk, sparing the limbs
  • Lymphadenopathy: suboccipital and postauricular (classic)
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41
Q

How is diagnosis of rubella confirmed?

A

Detection of rubella-specific IgM or a significant risk in rubella-specific IgG

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42
Q

What is the duration of the rash in rubella?

A

2-3 days

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43
Q

When are individuals infectious in rubella?

A

From 7 days before symptoms appear to 4 days after the onset of the rash

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44
Q

Is there an isolation period required with rubella?

A

Patients should stay away from school/ work at least 5 days after the development of the rash and avoid contact with pregnant women (particularly non-immune in their first trimester)

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45
Q

What are the compliactions of rubella?

A
  • Arthritis and arthralgia (most common in adult women)
  • Thrombocytopaenia
  • Encephalitis
  • Myocarditis
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46
Q

What should be done if there is clinical suspicion of rubella?

A

Inform the local HPT as rubella is a notifiable disease (within 3 days)

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47
Q

What is the management for rubella?

A
  • Usually self-limiting that resolves within a week
  • Rest
  • Adequate fluid intake
  • Paracetamol/ ibuprofen for symptomatic relief (aspirin avoided in children <16)
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48
Q

Which fetal abnormalities are caused by congenital rubella syndrome?

A
  • Cataracts
  • Sensorineural deafness
  • Patent ductus arteriosus
  • Brain damage
  • Retinopathy
  • Microcephaly
  • Hydrocephalus (rubella can cause aqueductal stenosis)
  • Low birth weight
  • Organ dysfunction
49
Q

What is the incubation period of roseola?

A

10 days

50
Q

What causes roseola?

A

Human herpes virus 6

51
Q

In which age group is roseola most common?

A

6 months to 2 years

52
Q

What is the presentation of roseola?

A
  • Initial febrile phase lasting 3-7 days, fevers can reach 40 degrees celcius
  • Lethargy
  • As the fever subsides a maculopapular rash (rose-pink macules with surrounding pale halos) predominantly over the trunk (may spread to face and limbs)
  • Nagayama spots (papular enanthem on the uvula and soft palate)
  • Diarrhea and cough
  • Febrile convulsions (10-15%)
53
Q

How is roseola diagnosed?

A

Typically clinically (high fever followed by rash)

In certain cases or severe manifestations, serologic testing or PCR for HHV6

54
Q

What are some other possible consequences of HHV6 infection?

A
  • Aseptic meningitis
  • Hepatitis
55
Q

Is school exclusion needed for roseola?

A

No

56
Q

How long does the rash last in roseola?

A

1 day

57
Q

What is the management of roseola?

A
  • Supprotive treatment, oral hydration
  • Paracetamol/ ibuprofen for symptomatic management
  • Monitor for complications
58
Q

What is the incubation period of mumps?

A

16-21 days

59
Q

What is mumps?

A

An acute systemic infectious disease caused by an RNA paramyxovirus

60
Q

How is mumps spread?

A

By respiratory droplets

61
Q

What is the presentation of mumps?

A
  • Flu-like prodrome
  • Parotitis (usually unilateral initially and becomes bilateral), lasting 3-4 days (almost always)
  • Epididymo-orchitis (usually 4-5 days after the onset of parotitis, uncommon in pre-pubertal)
  • Aseptic meningitis (usually self limiting, 4-25% of cases)
  • Encephalitis (rare)
  • Deafness (rare)
  • Pancreatitis
  • Nephritis
  • Arthritis
  • Thyroiditis
  • Pericarditis
62
Q

Who should be notified about a mumps outbreak?

A

Local HPU

63
Q

What are the investigations for mumps?

A
  • Usually clinical diagnosis
  • Need lab confirmation of salivary IgM mumps antibodies
  • Can complete serum mumps IgM, IgG/ PCR
64
Q

What is the management of mumps?

A
  • Self-limiting, usually resolves over 1-2 weeks
  • Rest, adequate fluids
  • Paracetamol/ ibuprofen for symptomatic relief
  • Apply warm/ cold packs to the parotid glands if needed
65
Q

When is admission to hospital required in mumps?

A
  • Signs of mumps encephalitis
  • Development of mumps meningitis
  • Following epididymo-orchitis (particularly bilateral), abnormal semen analysis, or infertility
66
Q

How long should mumps patients isolate?

A

5 days after onset of parotitis

67
Q

What are the clinical features of scarlet fever?

A
  • Sore throat (tonsillitis)
  • Fever
  • Headache, fatigue, nausea, vomiting
  • Blanching rash
68
Q

When does the rash develop in scarlet fever?

A

12-48 hours after initial symptoms

69
Q

What is the character of scarlet fever rash?

A
  • Red, generalised and pinpoint (punctuate) with a rough, sandpaper texture
  • Strawberry tongue
  • Generally appears first on the torso
70
Q

What’s typically spared in Scarlet fever?

A

Palms and soles of feet

71
Q

What are Forchheimer spots?

A

Small red spots on the hard and soft palate associated with scarlet fever

72
Q

What is scarlet fever caused by?

A

A reaction to erythrogenic toxins produced by group A haemolytic strep (usually strep pyogenes)

73
Q

When is the peak incidence?

A

4 years old (common in 2-6 years)

74
Q

What is the mode of transmission of scarlet fever?

A

Inhalation of respiratory droplets

75
Q

What is the incubation period of scarlet fever?

A

2-4 days

76
Q

What are the investigations for scarlet fever?

A
  • Throat swab for group A strep
  • Measurement of serum anti-streptolysin O (ASO antibodies), not useful in acute infection but may be helpful in diagnosing post infection complications
77
Q

When should a throat swab be taken in scarlet fever?

A
  • Uncertainty about the diagnosis
  • Suspected scarlet fever outbreak (local HPT notified within 3 days)
  • Allergy to penicillin (determine antimicrobial susceptibility)
  • Regular contact with vulnerable people at high risk of complications
78
Q

What is the management of scarlet fever?

A
  • 1st line: Phenoxymethylpenicillin (penicillin V) for 10 days
  • 2nd line: 0-6 months clarithromycin 10 days, 6 months-17 years azithromycin 5 days (or clarith 10 days)
79
Q

How long should children with scarlet fever be excluded from school/ nursery?

A

At least 24 hours after antibiotic treatment

80
Q

When should patients with scarlet fever follow up?

A

If symptoms haven’t improved within 7 days

81
Q

What are the complications of scarlet fever?

A
  • Otitis media (most common)
  • Rheumatic fever (20 days after infection)
  • Acute glomerulonephritis (10 days after infection)
  • Invasive complications (bacteraemia, meningitis, necrotizing fasciitis etc)
82
Q

What is the virus causing chickenpox known as?

A

Varicella zoster virus or human alphaherpesvirus 3 (HHV-3)

83
Q

How does chickenpox present?

A
  • Macules on the scalp, face, trunk and limbs which progress (12-14 hours) to papules, clear vesicles (itchy) and pustules
  • Vesicles can occur on palms, soles and mucous membranes
  • Shallow oral/ genital ulcers
84
Q

What are the complications of chicken pox?

A

Secondary bacterial infection of skin lesions, pneumonia and encephalitis

85
Q

How is chickenpox diagnosed?

A

Usually clinically, but lab tests can be used for confirmation

86
Q

What is the mode of transmission of chicken pox?

A

Respiratory droplets, direct contact with blisters, saliva or mucus

87
Q

What is the incubation period of chickenpox?

A

10-21 days

88
Q

When is someone with chickenpox infectious?

A

4 days before rash onset, 5 days after the rash has appeared

89
Q

What is the management of chickenpox?

A

Supportive
- Keep cool, trip nails
- Calamine lotion
- School exclusion (until 5 days after appearance of rash)

90
Q

Which patients with chickenpox should receive VZIG?

A

Immunocompromised and newborn patients

If chickenpox develops in these patients, IV acyclovir should be considered

91
Q

What is shingles?

A

A reactivation of the dormant virus in dorsal root ganglion

92
Q

What are some specific signs of meningitis?

A
  • Non-blanching rash (meningococcal)
  • Stiff neck
  • Photophobia
  • Bulging fontanella
  • Kernig’s sign
  • Brudzinski’s sign
  • Some children with bacterial meningitis present with seizures

Children presenting with specific signs are more likely to have bacterial meningitis

93
Q

How does the non-blanching rash present?

A
  • Petechial (macules <2mm)
  • Purpuric (macules >2mm)
94
Q

What are the most common causes of viral meningitis?

A
  • Enteroviruses (coxsackie A and B viruses and echoviruses), most common cause
  • HSV (usually a complication of primary genital herpes, not commonly seen in children)
95
Q

What is the most common cause of fungal meningitis?

A

Cryptococcus neoformans (immunocompromised individuals)

96
Q

Which drugs can cause drug induced meningitis?

A
  • NSAIDs
  • Trimethoprim/ sulfamethoxazole
  • Amoxicillin
  • Ranitidine
97
Q

What is the management of suspected bacterial meningitis?

A

Benzylpenicillin (IV or IM)
- <1 300mg
- 1-9 600mg
- >10 1200mg

98
Q

When would benzylpenicillin be withheld in someone with suspected bacterial meningitis?

A

If they have a history of penicillin induced anaphylaxis

99
Q

What is the pre-hospital management of meningitis without a non-blanching rash?

A

Urgent transfer to hospital, do not give parenteral antibiotics unless urgent transfer to hospital isn’t possible

Empiric antibiotics depend on availability/ local policy:
- Benzylpenicillin
- Cefotaxime
- Chloramphenicol

100
Q

What are the warning signs for bacterial meningitis that warrant senior review?

A
  • Rapidly progressive rash
  • Poor peripheral perfusion
  • Low or high resp rate or low or high pulse rate
  • pH <7.3 or WBC <4*10^9/L or lactate >4 mmol/L
  • GCS <12 or a drop of 2 points
  • Poor response to fluid resuscitation
101
Q

When should LP be delayed in suspected meningitis?

A
  • Severe sepsis or rapidly evolving rash
  • Severe respiratory/ cardiac compromise
  • Significant bleeding risk
  • Signs of raised ICP
102
Q

What is the management for patients with bacterial meningitis in hospital?

A
  • IV access (bloods + blood cultures)
  • IV abx: 3 months - 50 years ceftriaxone/ cefotaxime, >50 cefotaxime + amoxicillin
  • IV dexamethasone (avoid in meningococcal septicaemia/ immunocompromised, mainly for adults)
103
Q

What is the antibiotic management of meningitis in <3 months?

A

IV cefotaxime + amoxicillin (or ampicillin)

104
Q

What is the antibiotic management for meningococcal meningitis in hospital?

A

IV benzylpenicillin or cefotaxime (or ceftriaxone)

105
Q

What is the antibiotic management for meningitis caused by listeria?

A

IV amoxicillin (or ampicillin) + gentamicin

106
Q

What antibiotics should be given in bacterial meningitis if the patient is allergic to penicillin or cephalosporins?

A

Chloramphenicol

107
Q

When should meningitis contacts be offered prophylactic antibiotics?

A

If they have had close contact within 7 days of meningitis onset

108
Q

What are the prophylactic antibiotics given to meningitis contacts?

A

Oral ciprofloxacin or rifampicin (ciprofloxacin is the drug of choice)

109
Q

When should the meningococcal vaccination be offered to contacts?

A

When serotype results are available, including booster doses to those who have had the vaccine in infancy

110
Q

What are the viral causes of meningitis?

A
  • Non-polio enteroviruses eg. coxackie virus, echovirus
  • Mumps
  • HSV, CMV, herpes zoster viruses
  • HIV
  • Measles
111
Q

What are the risk factors for viral meningitis?

A
  • Patients at the extremes of ages (<5 and the elderly)
  • Immunocompromised
  • IVDU
112
Q

What would seizures suggest in a suspected meningitis patient?

A

Meningoencephalitis

113
Q

What is the management of meningitis while awaiting LP results, with suspicion of bacterial cause?

A

Broad-spectrum abx with CNS penetration eg. ceftriaxone and acyclovir IV

114
Q

What is the management of viral meningitis?

A
  • Supportive with symptoms resolving over 7-14 days
  • Acyclovir if the patient is suspected of meningitis secondary to HSV
115
Q

What bacteria causes meningococcal infection?

A

Neisseria meningitidis
Gram -ve intracellular diplococcus

116
Q

Which bacteria most commonly cause meningitis in neonates?

A
  • E.coli
  • Group B strep
117
Q

What is the prophylactic dose of ciprofloxacin given to meningitis contacts?

A

Single dose of oral ciprofloxacin

118
Q

What is the prophylactic dose of rifampicin given to meningitis contacts?

A

Oral twice a day for 2 days

119
Q

Why should NSAIDs not be given to a patient with chicken pox?

A

NSAIDs can increase the risk of necrotising fasciitis

Paediatrics (16 decks)

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