Fever and Rash in a Two Year-Old 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 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

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

18. 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

28. 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