Grand Rounds

Fever with rash

Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

Clinical Problem :
A 1½ year old girl presented with fever for 15 days and erythematous rash 12 days ago that lasted for 5 days. There is no cough, vomiting, loose motions or altered sensorium. She was treated with multiple antibiotics but fever did not respond. On examination, vital parameters were normal. She had red lips with peelings over the hands. Other systems were normal. There was no lymphadenopathy.

What is the diagnosis_?

Discussion :
This child had fever with rash. Fever with rash may be due to infectious causes, autoimmune disorders, vasculitis, drug reaction or even malignancy. In most viral exanthemas usually the fever subsides with onset of rash or along with the rash. It is very unusual for the fever to persist even when rash has disappeared. Rash with malignancy is usually due to petechiae or purpura and has associated other bleeding tendencies, anemia and bone tenderness with organomegaly. Drug reaction can also lead to rash but rash is usually itchy and subsides with antihistamines. It may be urticarial. Drug hypersensitivity can lead to Steven Johnson syndrome in which case mucocutaneous wide spread eruptions with desquamation will be present which is not there in this case. Thus autoimmune disorder or vasculitis is the most likely cause. Autoimmune disorders with fever and rash as presentation may be systemic onset JIA. However there would be subsequent joint involvement, organomegaly or lymphadenopathy which is not seen in this child.

Thus one should suspect vasculitis. Common vasculitis in children is Kawasaki disease associated with fever, rash, strawberry tongue, cervical lymphadenopathy, conjunctival congestion and subsequent desquamation of skin. In this child, all features are present except cervical lymphadenopathy and conjunctival congestion. However, it is not necessary that all features of Kawasaki disease be present as some may evolve over time. Thus, most likely diagnosis in this child is Kawasaki disease. In this child, echocardiography showed coronary dilatation, ESR was 120 mm at end of 1 hour and platelet count was 8,00,000, cunn. Treatment with Intravenous Immunoglobulin {IVIG} led to resolution of fever.

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