7 year old girl who was healthy except for occasional episodes of wheezing presenting with fever and maculo papular rash all over body on 6th day of fever.She used to have episodes of wheezing from three year onward which used to subside with inhalation of beta agonist and last for one or two days .No continuous medications .Last month she was hospitalized for an episode of wheezing running nose and fever ,needed hospitalization for a week . She was treated with par-enteral antibiotics .Fever and dyspnoea was relieved but morning cough was persisting . She was afebrile for a week and fever started again . This time there was no running nose. no sore throat ,no bowel or urinary disturbances. Cough was persisting as such in the morning hours . She had some body ache , left shoulder and left elbow pain a bit more severe , but no swelling , No other joints like small joints , spine or neck .No head ache altered sensorium vomiting .In the hospital this time she was on inj. Ampicillin and Inj Cefotaxime . She was not sick , was walking around .Skin rashes appeared first on the abdomen and within 12 hours it spread through out body . Palms , soles not involved , oral mucosa genitals were not involved. No significant eye congestion ,visual problems or eye pain . No other type of skin lesions , no bleeding manifestations on skin ,subcutaneous tissue bowel or urine.There was not much of itching , she was already on Atarax .
O/E.
Her vitals stable , (BP 100/66) ,pulse 92 per minute , good volume ,capillary refill time 2 sec . Minimal flushing of skin .Respiratory rate was 30 per minute. Her temperature 101 deg F. Fully conscious, oriented answering questions. No jaundice, no bleeds on conjunctiva , but mild congestion of palpebral conjunctiva. Cervical lymph nodes on the right side were palpable significant 1.5 cm, multiple non matted, with minimal tenderness. Few axillary lymph nodes also, same size discrete .Her anthropometric measurements showed above 80 percent weight for age, height normal. Rashes were mainly distributed around the trunk, neck and thighs especially over front aspect. Face lower legs and hands affected, but less. No lesions on palms and soles, lips, oral mucosa spared .Throat normal, No patch or bleed or ulcers in the throat, palate or oral mucosa .Joint examination showed left shoulder and left elbow pain on movement but no obvious swelling or signs of inflammation, All other joints were normal.
Diagnostic approach.
Main features are fever and rash in a seven year old girl child .Main group of entities which is likely to lead to this combination are
- Infections
- Connective tissue disorders
3 Fever and rash unrelated eg drug or another reason
How ll you proceed to make out which is which
First step 1. What about vital signs. is the child stable. There are situations where this sort of situations child is brought in an unstable state ,eg shock , respiratory distress , coma , seizure etc eg many among the above group , dengue ,meningococcemia, ricketsiels with some of the complications, connective tissue disorders with some complications , leptospirosis with encephalopathies. List is long in this situations also. You may add to this list . Few situations may be unrelated to the basic problem eg fluid loss and shock, or drug related complications. In this girl her vitals are stable .
There is another point which is helpful in the vitals. We considered the low BP state, what if the BP is on higher side? Yes it can occur, in that state possibility of connective tissue disorder, rare possibility of an infection involving kidney or causing raised ICT, drug related
Step II
Details of fever and the relation of the rash with the fever are useful here. You may refer to the onset of rash in relation with fever. Day 1 rash , day 2 rash ,day 3 rash ,day 4 rash all argues for certain entities, They are not hard and fast rules but helpful .
Here it was high grade fever, rash appeared after five days of fever. How this is helpful? First entity any doctor in our country should consider in a patient with fever and maculopapular rash is measles, as that is the commonest entity. But is it fitting with measles? What are the strongest argument points against measles?
- There is no running nose.
- Cough not predominant, she is having cough only in the morning hours which was of same severity as she had during the asthma episode
3 .The rash did nt proceed in the usual pattern, from face, down .
4 The rash did not involve the palms, mucosa , eyes
5 She is immunized, but mind you this point is not a strong point as we do see a lot of failure in case of single dose of measles .They come in a modified style
- One point i forgot to mention in the examination, there was no Koplik spot. Koplik spot again should be used cautiously. The presence of koplik argues for measles, but absence does no t rule out. It is transient.
The time relation of rash with fever in fact is not fitting with most of the common infections. What about Rubella? Again the rash won’t be that late. The fever won’t be that high grade. Joint pain is arguing for it. But most important finding is sub occipital lymph node. Here sub occipital lymph nodes were not enlarged. One more point, useful is vaccination history. To be frank i forgot to ask this point. i ll ..She is in the ward.
What about other viral infection?
Her vitals stable,
Does that totally rule out dengue? . No it is still possible. Only severe grades of dengue need have unstable vitals .One point against is the late onset of rash, a bit unlikely. Joint involvement is arguing for chickun guinea, Absence of muscle tenderness, conjunctival congestion is arguing against. Still we need to consider dengue and chicken guineas as strong possibilities. So we were looking for other signs like cutaneous bleeds, Of course here before we send for lab investigations we can do Tourniquet test on the bedside. (To be frank we did not do it. Only when i write this i remember what all things we are missing when we actually do in the ward)
Few more of the viral infections which can present with fever, like parvo , adeno , coxakie ,echo etc but a high grade fever and fever lasting this long we should not consider this entities as we may miss important entities
What other infection, treatable, which we did nt consider so far, can present with fever and maculopapular rash, without running nose? Leptospirosis . Here what points for and against? In fact many points are not arguing for. No muscle pain, No jaundice, No bleeding tendency, P/A no liver spleen. There are few lymph nodes in the neck, minimal conj congestion .Can we rule out that possibility totally? NO, being a treatable entity, and likely to have modified manifestation this entity should be one of the DDs always, till you rule out for sure. And empirical treatment is justified if you are not in a position to rule out
Should we consider other bacterial infections which can cause fever eg enteric fever .Enteric fever can cause rash, but not this extensive and lasting. So less chance for enteric fever directly leading to this rash. Of course we were considering the possibility of drug rash on another condition with fever. She was on cefotaxime and Ampicillin for two days before she was referred here. Does that remind you something which you learned? In a case of fever, rash. And relation of Ampicillin. Yes Infectious mononucleosis. Of course that possibility to be considered high in the list. Fever, rash , few lymph nodes in the neck , axilla. Hepato splenomegaly need not be there in all cases. Throat was normal , this is a better point to argue against IMN , but again not in hundred percent of case. Absence of jaundice, you may use for argument, Again it is not a hard point. Toxo plasma and cytomegalovirus causes similar picture which the investigation only will rule out
Which other infections we did nt consider so far?
Ricketsiels, secondary syphilis. Lot of atypical presentations of ricketsiels we encounter now in this area. The rash typically involves the palms and soles. And we should look for Eschar. in this case both were not there.
So next thing.
Are we dealing with infection? is it something else
Is it drug ?
is it connective tissue disorder ?
Drug as a reason can t be rule out for sure, as this occurred on the second day of antibiotics. Not much of itching. no mucosal involvement are weak points to argue against that possibility . So we stopped all drugs. In this case we don’t have a firm diagnosis. Patient’s vitals stable.
Should we consider possibility of connective tissue disorder? Yes , we should , in a girl child of this age. They can present like this. May be acute. But of course common things common , we consider infection possibility as 90 percent , and the investigations for Connective tissue disorders are costly ,she did nt have any major markers to argue for connective tissue disorder. So we planned to do the costly investigations in the next stage. Of course we ll do the basic minimum in all cases eg counts. ESR, CRP, Urine which may give some clues in this line
Now the investigations
Total count 8000 /cmm. i dont remember the HB i think it was normal
DC Neutrophil 70 %,Lymph25 E 5. Platelet 2.7 lakh
ESR 70
Urine alb nil, microscopy nil , no bile salt ,bile pig
Renal function Urea 18, Creatinin 0.9
LFT , bilirubin 0.9 total and direct 0.2 ,Total proteiin 7 , alb 4 , SGPT 45,SGOT 40
So where are we now?
Counts, not that high, with a high ESR. Normal Urine parameters and Normal LFT. i can defintely rule out Lepto . Only High ESR is arguing all other parameters against .Even anicteric lepto SGPT ll be high
Count does that suggest dengue. Not that low, normal platelets. and high ESR . Not suggestive, but can’t rule out. So we send for Ig M dengue. Not NS 1 as it is already 7th day
What about IMN , Toxoplasma, Cytomegalovirus. Yes possibility is unlikely with this count and neutrophil predominant picture. Still we send for a peripheral smear. One more dictum, any prolonged fever peripheral smear thick and thin should be done as we are living in India and malaria can be one of the DDs of any of this sort of cases. I am not sure what was the result of PS. i ll update tomorrow
So what about possibility of a connective tissue disorder
Should we consider Kawasaki ?
This age, very rare , No mucosal involvement , chances are very low
High ESR with Low count, always SLE to be ruled out
So we plan to rule out in the next week.
What did we do?
My first diagnosis in this case of fever with rash happening on the seventh day, not sick with few lymph nodes , normal system findings was ricketsiels , atypical manifestation
Yesterday we send for Weil Felix and IgM Eliza for Scrub typhus
As we were not sure of drug as a reason, we took all investigations , stopped all parenteral antibiotics and put her on Doxycycline 100 mg daily
Today morning she is afebrile
We are yet to get the report of tests . I ll update
19/04/2016
Weil felix test came as negative
IgM Eliza not done
So where are we now .
As jom suggested , may be it is just viral infection with rash spontaneously remitted and we were attributing response to doxicycline
Weil felix may be false negative
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