Fever and Rash in a Two Year-Old Fever and Rash in a Two Year-Old ChildChild

James A. Wilde MD, FAAP

Assistant Professor of Emergency Medicine and Pediatrics

Medical College of Georgia

Augusta, Georgia

First ED VisitFirst ED Visit

• Two year-old male with history of fever and rash for 12 hours

• Mom suspects headache because he puts his hand to his head periodically

• 90/60, 120, 26, 38.9C (rectal)• No vomiting or diarrhea, no upper

respiratory infection symptoms• Still eating and drinking

Past Medical/Social HistoryPast Medical/Social History

• No recent trauma

• No history of headaches

• PMH unremarkable

• Vaccinations up to date

• Lives with Mom/Dad/5 yo sibling; all well

• Attends Day Care

Exam: First VisitExam: First Visit

• Alert, oriented, subdued but not lethargic

• Quiet on Mom’s lap but fights exam vigorously

• Well hydrated, PERRL, EOMI, no photophobia, normal tympanic membranes and pharynx, supple neck, slight rhinorrhea, normal neuro exam

• Scattered erythematous, blanching macules 5 mm to 2 cm trunk and arms

ED Therapy and Work UpED Therapy and Work Up

• Ibuprofen for fever

• No laboratory tests ordered

• Observed in Emergency Department for one hour

ED Disposition: Visit 1ED Disposition: Visit 1

• Fever slightly reduced 60 minutes after ibuprofen given

• Parents told symptoms compatible with a viral infection

• Instructed to expect fever for 3-5 days, see their doctor or return if symptoms worsen significantly or for purple rash

22ndnd ED Visit ED Visit(12 hours after 1(12 hours after 1stst ED visit) ED visit)

• Worsening oral intake, increasingly lethargic, vomiting, rash worse

• Several purple spots now on arms

• Sleeping much more

• 84/56, 140, 32, 39.4C (rectal)

Exam: 2Exam: 2ndnd Visit Visit

• Sleepy, unwilling to sit without support but does awaken and push MD away

• 84/56, 140, 32, 39.4C (rectal)• Impaired flexion at neck• Tacky mucous membranes• No focal neurologic abnormalities• Several purpuric lesions trunk and arms

ED Therapy & Work UpED Therapy & Work Up

• Blood obtained for CBC, culture, electrolytes. Urine for urinalysis and culture.

• Bolus of normal saline 10 cc/kg, followed by continuous fluids at 2/3 maintenance

• Head computed tomography (CT) ordered

ED CourseED Course

• Delay in obtaining CT due to multiple trauma victims in ED, finally done in 1 hr

• CT read as normal 15 minutes later• Lumbar puncture performed 30 minutes after

head CT• CSF grossly cloudy• Ceftriaxone 75 mg/kg administered IV• Admitted to Pediatric Intensive Care Unit

ED Admitting DiagnosesED Admitting Diagnoses

• Meningitis

• Meningococcemia

Pediatric Bacterial MeningitisPediatric Bacterial Meningitis

• Increasingly rare diagnosis, particularly since introduction of H. flu B conjugate vaccine

• Estimated 2800 cases nationwide in 1995 in children under 18

• Risk per febrile illness in children under 5 years is less than one in four thousand

Common PathogensCommon Pathogens

• Varies by age of child• Group B streptococcus, Escherichia coli in

neonates• Streptococcus pneumoniae, Neisseria meningitidis

in children over 2-3 months

• Strep pneumoniae most likely up to 23 months• N meningitidis most likely from 2-18 years

PathophysiologyPathophysiology

• Almost always preceded by hematogenous spread

• Access to vascular space may be linked to breach in mucosal barrier during URI

• Entry into CNS via unclear mechanism

• Poor immunologic defenses in CSF allow relatively unimpeded replication initially

Pathophysiology IIPathophysiology II

• Release of chemotactic factors from bacteria causes mobilization of host defenses

• Increasing inflammation and edema as host defenses become active

• Inflammation and edema contribute directly and indirectly to infarction and necrosis

ED Presentation: ED Presentation: Pediatric Bacterial MeningitisPediatric Bacterial Meningitis

• Depends on the age of the child

• Can be subtle in neonates• Poor feeding • Increased sleep• Respiratory distress• Fever absent in half

• Children under one year of age outside neonatal period may exhibit nuchal rigidity but often do not• Fever• Lethargy• Poor feeding• Irritability• Altered sensorium• Vomiting

ED Presentation: ED Presentation: Pediatric Bacterial MeningitisPediatric Bacterial Meningitis

• Symptoms more specific as the age increases beyond one year• Fever• Headache• Nuchal rigidity• Altered sensorium• Vomiting • Photophobia

ED Presentation: ED Presentation: Pediatric Bacterial MeningitisPediatric Bacterial Meningitis

Diagnostic StudiesDiagnostic Studies

• Blood culture is essential

• CBC, electrolytes

• LP

• Chest radiograph if respiratory symptoms

Timing of Lumbar PunctureTiming of Lumbar Puncture

• Not essential to perform before antibiotics given

• Inflammation and CSF pleocytosis worsen during first several days of therapy

• Lumbar puncture after antibiotics does not hinder ability to make diagnosis

Timing of AntibioticsTiming of Antibiotics

• Should be given expeditiously

• No specific recommendation for timing of antibiotics can be directly supported

• Laboratory data in animals suggest the sooner antibiotics are given, the better

Head Computed TomographyHead Computed Tomography

• Not indicated if clinical presentation consistent with uncomplicated bacterial meningitis

• May be indicated in selected patients• Focal neurologic deficits• Evidence for severely increased ICP• Comatose

• Most children do not need head CT

Fluid ManagementFluid Management

• Fluid restriction no longer recommended

• Some laboratory and clinical data indicate there may be a protective effect from SIADH in meningitis

• Manage hypotension in similar fashion to patient with sepsis: fluids first

Steroids in MeningitisSteroids in Meningitis

• Consensus on benefit only for cases due to Haemophilus influenzae

• Current edition of pediatric “Red Book” recommends only for H flu disease

• Meningitis due to Haemophilus influenzae now extremely rare

ED ManagementED Management

• Manage hypotension as per standard protocols

• Obtain blood culture• Administer antibiotics• Perform LP if patient stable and no

contraindications• Head CT in selected cases• Check gram stain results***

Antibiotic TherapyAntibiotic Therapy

• Ampicillin and gentamicin/third generation cephalosporin in neonates

• Vancomycin and Ceftriaxone in children over the age of two months

ConsultsConsults

• Pediatric ID

• Pediatric ICU

Outcome of CaseOutcome of Case

• Day 1: Seizure, DIC, purpuric lesions on fingers and toes

• Day 2: No further spread of purpuric lesions, afebrile

• Day 3: N meningitidis isolated from blood/CSF • Day 5: Normal audiologic examination• Day 10: Necrosis of finger tips• Day 14: Discharged with plans for surgical F/U