Acute Rash and Fever

Presenting Complaint

• Louise is worried about her son’s rash that he has developed. The rash is over his stomach. ‘He’s had a sore throat and a fever for a few days now but this morning he woke up with this rash and I’m really concerned.’

Symptoms (SOCRATES)

• Site: trunk - ‘it’s just all over his stomach’ 
• Onset: this morning ‘I just saw it for the first time when I was getting him dressed this morning’ 
• Character: maculopapular erythematous rash 
• Radiation: N/A
• Associated symptoms: fever, sore throat
• Time: fever for 5 days, rash this AM - ‘he’s had a fever for the last few days and the rash just appeared this morning’
• Exacerbating/Alleviating factors: ‘I’ve given him some calpol for his fever but it’s done nothing’
• Severity: N/A
• Other:
  • Not been eating as much recently, normally a very hungry boy who likes his food, but this week it’s been hard to get a full meal in him 
  • Been a little quieter recently, less playful, mostly lying on the sofa watching movies  
  • Sleeping longer, has needed a nap in the afternoon for the last few days which he normally doesn’t do 

Systemic symptoms

• Fever
• Sore throat 
• Rashes or Skin Changes: maculopapular erythematous rash, the rash does blanch 
• Eye changes: bilaterally red conjunctiva
• Throat/mouth changes: red, swollen tongue and a red throat 
• Night Sweats: None
• Unintended Weight Loss: No
• Shortness of Breath or Cough: None
• Headache: None
• Change in Bowel Habits: None
• Urinary symptoms: None

Past Medical History: 

• No significant medical conditions 
• No previous surgeries or hospitalisations 
• No previous injuries or traumas

Drug History:

• Has taken calpol for the last few days for his fever 
• No other current medications 
• No use of herbal supplements or alternative therapies

Allergies: 

• Cows milk as a baby but has grown out of this 

Social History:

• Family: mum, dad and older brother (10 y/o) live at home 
• Care: mum and dad look after him, part-time at nursery 
• Nursery: no issues, really loves it there 
• Parental occupations: mum is a software engineer, dad is a stay at home parent 
• Parental smoking: nil 
• Pets: one cat 
• Hobbies: he goes to a play group once a week at the library

Family History: 

• Mother: Asthma
• Father: Nil
• Brother: Eczema

Child Health Specific: 

• Up to date with all vaccines
• Birth Hx 
  • 39+6 weeks
  • Pregnancy normal, no complications 
  • Vaginal delivery 
  • Born in Glasgow  
  • No issues postnatally bar the cows milk allergy 
• Feeding: eats well at home, not picky, enjoys his food
• Developmental milestones: all achieved, no delays 
• School: he is in nursery part-time
• No children at nursery are sick, neither is his brother 

Ideas, Concerns, and Expectations: 

• Ideas: ‘I think he may have a bit of a bug.’ 
• Concerns: ‘I’m just a bit worried, I’ve heard about meningitis and that having a rash? I’m also worried that I can’t get his fever down with calpol.’ 
• Expectations: ‘I’d just like him looked over to make sure it’s nothing serious.’

Observations: *PEWS chart below can be shown for values* 

• Respirations (Breaths/min): 38
• Oxygen Saturation (%): 98%
• Air or Oxygen: RA
• Blood Pressure (mmHg): 95/60
• Pulse (Beats/min): 145
• Consciousness (AVPU): A
• Temperature (Celsius): 38.2
• PEWS Total Score: 3

Physical Examination: *assume that the examination can be done on either a dummy or adult volunteer* *show pictures to student when they say they are looking in the throat/ looking at the stomach or exposing their patient* 

End of bed: very quiet child, looks quite flat and tired 

• A: airway patent, no secretions or stridor
• B: no signs of respiratory distress, auscultation is normal 
• C: good color, cap refill normal, HS I + II + 0
• D: pupils normal, alert but tired, glucose is normal 
• E: rash as below, cervical LN can be palpated
• ENT: ears fine, nose fine, throat is red and inflamed + tongue pictured below
• Tummy: rash as below, SNT

Examiner questions: 

‘What are your differential diagnoses?’ 

1. Kawasaki: correct age, strawberry tongue, rash, conjunctivitis, fever prodrome
2. Scarlet fever: febrile child with a strawberry tongue. However they would not have ocular Sx and would have a sandpaper rash instead. 
3. Measles: febrile child with conjunctivitis and a maculopapular rash. The rash looks slightly different in measles. Additionally these children would have a cough and a runny nose, which isn’t typical in Kawasaki’s.
4. Staphylococcal scalded skin: although this could cause a fever and some oral signs, this would result in a blistering rash and peeling of the skin.
5. Eczema: his older brother has eczema however the rash is very different and he would not present with all the other symptoms.
6. Allergic reaction: although an allergic reaction can result in a rash and conjunctivitis, it would be unlikely to cause a fever and strawberry tongue. Furthermore, this is more likely to be a shorter history.  

‘What is the diagnosis?’ 

• Kawasaki disease
• ‘There is a complication that concerns us with Kawasaki disease, what is this complication and how do we test for it?’ 
• The complication is coronary artery aneurysms. This is tested for via an echocardiogram. These echocardiograms should be serial to determine disease progression. 

‘How do you treat Kawasaki’s disease?’

• IV immunoglobulins and high dose aspirin are the mainstay of Tx. Aspirin is given at a high dose in the acute phase for its anti-inflammatory properties, and then given at a low dose for a further 6-8 weeks due to its antiplatelet properties (vasculitis is pro-thrombotic). Calpol and nurofen can be considered for their antipyretic and analgesic properties. 

Patient questions (parent):

‘What do you think Milo has?’

• I think Milo has a condition called Kawasaki Disease. It’s a relatively rare condition that causes inflammation in his blood vessels. This inflammation is the reason he has the rash and his eyes and tongue are red. We don’t really know why it happens, but it generally does affect young children. 

‘Is this Kawasaki Disease dangerous?’ 

• Most of the time it’s a relatively harmless condition and children just get better on their own. However, in about 20% of children it can cause the blood vessels in the heart to weaken. That’s quite serious because it can damage the heart, which we don’t want. Because of this risk we treat every child with Kawasaki Disease very seriously and make sure we give them the right medication. 

‘How will you treat him?’

• We will start off by giving him some calpol and nurofen to bring his fever down. We are then going to give him some antibodies through a drip, this will help him bring down the inflammation and fight this off. We’re also going to give him some aspirin which will help reduce that inflammation in his blood vessels. All those will be given in hospital and then once you’re discharged we will give you some aspirin to take for a few weeks at home.