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

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

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

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

ED Therapy and Work Up Ibuprofen for fever No laboratory tests ordered Observed in Emergency Department for one hour

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

2 nd ED Visit (12 hours after 1 st 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: 2 nd Visit Exam: 2 nd 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 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 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 Diagnoses Meningitis Meningococcemia

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

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

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

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

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

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: Pediatric Bacterial Meningitis

Symptoms more specific as the age increases beyond one year Fever Headache Nuchal rigidity Altered sensorium Vomiting Photophobia ED Presentation: Pediatric Bacterial Meningitis

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

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

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

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

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

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

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***

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

Consults Pediatric ID Pediatric ICU

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