Fever and Rash in a Two YearOld Child

1
Fever and Rash in a Two Year-Old Child

• James A. Wilde MD, FAAP
• Assistant Professor of Emergency Medicine and
  Pediatrics
• Medical College of Georgia
• Augusta, Georgia

2
First 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

3
Past 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

4
Exam First Visit

• Alert, oriented, subdued but not lethargic
• Quiet on Moms 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

5
ED Therapy and Work Up

• Ibuprofen for fever
• No laboratory tests ordered
• Observed in Emergency Department for one hour

6
ED 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

7
2nd ED Visit(12 hours after 1st 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)

8
Exam 2nd 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

9
ED 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

10
ED 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

11
ED Admitting Diagnoses

• Meningitis
• Meningococcemia

12
Pediatric 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

13
Common 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

14
Pathophysiology

• 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

15
Pathophysiology 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

16
ED Presentation Pediatric Bacterial Meningitis

• Depends on the age of the child
• Can be subtle in neonates
• Poor feeding
• Increased sleep
• Respiratory distress
• Fever absent in half

17
ED Presentation Pediatric Bacterial Meningitis

• 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

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ED Presentation Pediatric Bacterial Meningitis

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

19
Diagnostic Studies

• Blood culture is essential
• CBC, electrolytes
• LP
• Chest radiograph if respiratory symptoms

20
Timing 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

21
Timing 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

22
Head 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

23
Fluid 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

24
Steroids 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

25
ED 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

26
Antibiotic Therapy

• Ampicillin and gentamicin/third generation
  cephalosporin in neonates
• Vancomycin and Ceftriaxone in children over the
  age of two months

27
Consults

• Pediatric ID
• Pediatric ICU

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Outcome 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