CH WK 3 CASE 3

Pyrexia and rash

In this case a child presents with a short history of pyrexia but also a non-blanching rash. Through this case you will explore causes of petechia, anaemia and look at some of the red flags for childhood oncology. As in previous cases you will be asked to think about differential diagnoses throughout your history, examination and investigations.

Pyrexia and rash ILOs

Pyrexia and rash – Guidance and Resources

In case Pyrexia and rash

eBooks

Illustrated Textbook of Paediatrics 4th edition. Lissauer (Mosby Elsevier)

Textbooks

Nelson Essentials of Pediatrics:, Karen Marcdante MD, Robert M. Kliegman MD

Web Links

Immunization-Schedule – Saudi Public Health

Developmental Milestones – CDC

CASE COMPONENT

Pyrexia and rash – Case Introduction

In case Pyrexia and rash

Ibrahim is a 3 year old boy who comes to see you in A/E with a temperature and a rash.

You are working in A/E as an FY2; you pick up his notes, the triage nurse has written:

3 yr old boy

2/7 history of pyrexia and coryzal symptoms

Rash started today ,?non blanching

You are now going to see Ibrahim and his dad. With your list of differential diagnosis in mind you are now going to ask a focused history.

Ibrahim’s Dad gives you the following history:

“Ibrahim was very well until 2 days ago when he started with a runny nose, cough and temperature. We have been giving him paracetamol and when his temperature is down is his ok eating and drinking and playing. When his temperature is up he is a bit sleepy. We have all been unwell with the cold.

We noticed the rash this morning but when he was getting ready for a bath this evening it had changed. We did the “glass test “ and it didn’t go away. It started on both calves and ankles.

Ibrahim had been colouring in this afternoon with his sister so we thought it maybe felt tip and gave it a good rub in the bath but it didn’t come off. He complained of a sore ankle while we were doing this but I didn’t rub hard and I don’t remember him bumping into anything”

You now have a lot of information. It can be helpful to separate your list of differential diagnoses by their likelihood:

These were Ibrahim’s findings aged 3 year 1 month:

Height – 93cm

Weight 12 kg

Plot Ibrahim's current weight (12kg) on the growth chart below by clicking on the relevant area

Plot Ibrahim's current height (93cm) on the growth chart below by clicking on the relevant area

· Temperature – 37.1C

· Heart rate – 85bpm

· Respiratory rate – 28 bpm

· Sats 98%

· Blood Pressure – 89/50

· Cap refill – <2 secs

He is playing on the computer but walks with a limp when you ask him to climb up on the bed

He does not look pale there is minimal cervical lymphadenopathy

He has a mild tickly cough and a runny nose. His chest is clear with no signs of increased work of breathing

Heart sounds were normal and his peripheries where warm

His abdomen was soft non distended, no tender with no organomegaly.

Testes were descended with no scrotal oedema

The right ankle was warm and swollen and painful on manipulation

Image of Ibrahim’s rash:

Calculate Ibrahim's PEWS score using the chart below:

Paediatric Early Warning Score (PEWS) Chart

Heart rate - 85bpm = 0

Respiratory rate - 28 bpm = 0

Sats 98% = 0

Blood Pressure - 89/50 = 0

Cap refill - <2 secs = 0

TOTAL = 0

The investigations showed that HSP was the most likely diagnosis which would fit with the clinical findings. There is often renal involvement with HSP which normally resolves but if not can cause significant morbidity.

Each unit has its own slightly different policy for monitoring but all children with HSP will have their BP and urine checked for renal involvement for up to a year after the rash resolves.

Note: The rash looks bad but it does not scar.

Useful Links:

· Henoch-Schönlein purpura – NHS Choices

· Henoch-Schonlein purpura – BMJ Best Practice (Institutional log-in required)

Immune thromboctopenic purpura

Another diagnosis to be aware of which was discussed in this case is Immune thrombocytopenic purpura. These children also present with petechial and purpura again often after a viral illness:

· Immune thrombocytopenic purpura (ITP) – The ITP Support Association

CASE COMPONENT

Pyrexia and rash – Further Case Information

In case Pyrexia and rash

Ibrahim returns the next day. He is complaining of severe abdominal pain, and painful testicles. You know that abdominal pain can be found with HSP as the gut is also affected with the vasculitis and that you can also get scrotal oedema, however there are two very important diagnosis which must also be considered.

Watch the following short presentation on intussesception by Mr Supul Hennayake:

Watch the following short presentation on testicular torsion by Mr Supul Hennayake:

Whilst taking the initial history from Dad he told you that 18months ago Ibrahim was admitted to the ward at your hospital with severe anaemia.

He was so unwell that he had needed a blood transfusion.

You decide to explore this further and request his old notes.

Whilst awaiting these you wonder if this could be related to his presenting complaint or something else. 

Anaemia happens when the level of healthy red blood cells in the body becomes too low. This can happen because:

1.    The body is destroying red blood cells

2.    Red blood cells are being lost

3.    The body is producing red blood cells too slowly

The table below lists various conditions and details how they cause anaemia:

You have now located his old discharge letter relating to the admission where his father said that he required a blood transfusion:

Patient: Ibrahim Ahmed – NHS No. 4329111306

Dear Dr Whitehead

Problems

1.    Severe iron deficiency anaemia Hb 30gm/L

2.    Evidence of symptomatic anaemia with transient innocent murmur and breathlessness

3.    Blood transfusion. Post transfusion Hb 50gm/L

4.    Nutritional deficient diet

5.    Increased BMI

6.    Delayed weaning

Medication

· Sytron 2.5mls bd to continue for at least 3/12

· Healthy vitamin D drops

Investigations

· FBC and film showed hypochromatic microcytic anaemia, no evidence of haemolysis or blast cells.

· Coombs test -ve

· Reticulocytes normal

· WBC and platelets norma

· LFT including bilirubin normal

· Ferritin 2ng/mL (low)

· Zinc protoporphryins elevated

· Serum Iron low

· total iron binding capacity high

· Neonatal screening no evidence of thalassemia or sickle cell

Management

· Dietary referral

· All bottles of milk stopped during admission

Ibrahim aged 18 months was admitted with a short history of breathlessness on minimal exertion, paleness and fatigue . He had a 6 month history of pica; eating paper and licking the walls. There was no history of any bleeding, diahorrea, trauma, heavy nosebleeds. He was found to have severe anaemia Hb 30gm/L . On examination he had no excessive bruising, no lymphadenopathy nor hepatosplenomegaly. His hands and radius were normal. He did not have any history of a rash or any prodromal illnesses.

His dietary history revealed that his mother was anaemic and had breast fed him for the first 8 months exclusively. Following on from his late weaning his diet consisted of egg custard, yogurt, cheese and 3 bottles of normal non formula cows milk during the day and 3 overnight.

Due the fact he was symptomatic we cautiously transfused him up by a few units and have commenced him on iron.

Investigations showed no other concerns in his bloods suggesting bone marrow issues. His murmur was felt to be innocent secondary to the anaemia.

Dietary advise was given to remove all bottles . To only use formula milk in cereals, to wean appropriately onto a fully varied diet and to increase iron and decrease the overall calorie intake.

We will review in a month to see how he is doing

Dr Smith

Patient: Ibrahim Ahmed – NHS No. 4329111306

Dear Dr Whitehead

Problems

1.    Severe iron deficiency anaemia Hb 30gm/L

2.    Evidence of symptomatic anaemia with transient innocent murmur and breathlessness

3.    Blood transfusion. Post transfusion Hb 50gm/L

4.    Nutritional deficient diet

5.    Increased BMI

6.    Delayed weaning

Medication

· Sytron 2.5mls bd to continue for at least 3/12

· Healthy vitamin D drops

Investigations

· FBC and film showed hypochromatic microcytic anaemia, no evidence of haemolysis or blast cells.

· Coombs test -ve

· Reticulocytes normal

· WBC and platelets norma

· LFT including bilirubin normal

· Ferritin 2ng/mL (low)

· Zinc protoporphryins elevated

· Serum Iron low

· total iron binding capacity high

· Neonatal screening no evidence of thalassemia or sickle cell

Management

· Dietary referral

· All bottles of milk stopped during admission

Ibrahim aged 18 months was admitted with a short history of breathlessness on minimal exertion, paleness and fatigue . He had a 6 month history of pica; eating paper and licking the walls. There was no history of any bleeding, diahorrea, trauma, heavy nosebleeds. He was found to have severe anaemia Hb 30gm/L . On examination he had no excessive bruising, no lymphadenopathy nor hepatosplenomegaly. His hands and radius were normal. He did not have any history of a rash or any prodromal illnesses.

His dietary history revealed that his mother was anaemic and had breast fed him for the first 8 months exclusively. Following on from his late weaning his diet consisted of egg custard, yogurt, cheese and 3 bottles of normal non formula cows milk during the day and 3 overnight.

Due the fact he was symptomatic we cautiously transfused him up by a few units and have commenced him on iron.

Investigations showed no other concerns in his bloods suggesting bone marrow issues. His murmur was felt to be innocent secondary to the anaemia.

Dietary advise was given to remove all bottles . To only use formula milk in cereals, to wean appropriately onto a fully varied diet and to increase iron and decrease the overall calorie intake.

We will review in a month to see how he is doing

Dr Smith

St4 General Paediatrics

Iron deficiency anaemia is unfortunately very common in children mostly secondary to nutrition. Although this case was fictional, children all too regularly are admitted with a very similar history. If poor nutrition can be spotted and corrected early as part of any health professional contact then histories like this can be prevented in the future.

So always ask!

· Iron deficiency anaemia – NHS Choices

· Heart Murmur – British Heart Foundation (BHF)

Throughout the letter above there are clues to the many different diagnosis of anaemia.

Take another look at the letter:

Patient: Ibrahim Ahmed – NHS No. 4329111306

Dear Dr Whitehead

Problems

1.    Severe iron deficiency anaemia Hb 30gm/L

2.    Evidence of symptomatic anaemia with transient innocent murmur and breathlessness

3.    Blood transfusion. Post transfusion Hb 50gm/L

4.    Nutritional deficient diet

5.    Increased BMI (thriving very well excludes many gut absorption causes, lots of excess calories in cows milk but not much else!)

6.    Delayed weaning

Medication

· Sytron 2.5mls bd to continue for at least 3/12

· Healthy vitamin D drops

Investigations

· FBC and film showed hypochromatic microcytic anaemia, no evidence of haemolysis or blast cells. (leukaemia and haemolytic anaemia)

· Coombs test -ve (looking for haemolytic anaemia)

· Reticulocytes normal (excludes red cell aplasia)

· WBC and platelets norma (show other cell lines intact, not a leukaemic picture)

· LFT including bilirubin normal (elevated in haemolytic disease)

· Ferritin 2ng/mL (low)

· Zinc protoporphryins elevated

· Serum Iron low

· total iron binding capacity high (these 4 results all indicate iron deficiency anaemia)

· Neonatal screening no evidence of thalassemia or sickle cell

Management

· Dietary referral

· All bottles of milk stopped during admission

Ibrahim aged 18 months was admitted with a short history of breathlessness on minimal exertion (suggestive that anaemia so severe element of cardiac failure present), paleness and fatigue . He had a 6 month history of pica; eating paper and licking the walls (anaemia). There was no history of any bleeding (blood loss), diahorrea (coeliac, IBD, cows milk protein enteropathy), trauma (blood loss), heavy nosebleeds (clotting disorders). He was found to have severe anaemia Hb 30gm/L . On examination he had no excessive bruising (leukaemia, clotting disorders, platelets either low or dysfunctional), no lymphadenopathy (leukaemia) nor hepatosplenomegaly (leukaemia, spherocytosis). His hands and radius were normal (Fanconi anaemia). He did not have any history of a rash or any prodromal illnesses (aplastic anaemia secondary to infection i.e. parvovirus B 19) .

His dietary history revealed that his mother was anaemic and had breast fed him for the first 8 months exclusively (very little iron in mothers milk if she is anaemic). Following on from his late weaning his diet consisted of egg custard, yogurt, cheese and 3 bottles of normal non formula cows milk during the day and 3 overnight (no real iron in any of these foods major in the iron deficiency anaemia).

Due the fact he was symptomatic we cautiously transfused him up by a few units and have commenced him on sytron.

Investigations showed no other concerns in his bloods suggesting bone marrow issues. His murmur was felt to be innocent secondary to the anaemia.

Dietary advise was given to remove all bottles . To only use formula milk (which is fortified with iron) in cereals, to wean appropriately onto a fully varied diet and to increase iron and decrease the overall calorie intake.

We will review in a month to see how he is doing

Dr Smith

St4 General Paediatrics

Use the links below to refresh your knowledge of anaemia and clotting disorders from Year 3:

Anaemia Case

Clotting Disorders Case

Sickle cell disease
Perpheral smear showing sickle cell anaemia.

About one in 2,000 babies born in the UK has a sickle cell disease (SCD). The incidence in tropical Africa can be as high as 40%. It is an autosomal recessive genetic disorder with overdominance characterised by red blood cells that can change to a sickle shape and become stuck in the small blood vessels. This can cause pain and damage to the baby’s body, serious infection, or even death. SCD presents after 6 months of age. There is high mortality in the first 5 years due to infection caused by Pneumococcus, Haemophilis or Salmonella.

As part of the NHS blood spot screening programme all newborn infants born in the UK are screened for SCD.

Peripheral smear from a patient suffering from Thalessemia major. RBC morphological changes include microcytosis, hypochromia, anisocytosis, poikilocytosis (spiculated tear-drop and elongated cells)], and nucleated RBC (i.e., erythroblasts). 

Pyrexia and rash – Background Science

In case Pyrexia and rash

Childhood Cancers

Although cancer is less common in children than in adults it unfortunately does still happen and it is really important to be aware of the different cancers that commonly affect children and to know the RED FLAGS.

Child Cancer Types – The Little Fighters Cancer Trust

This website is for parents of children with childhood cancers but gives a good, very simple overview to the common cancers and their presenting signs and symptoms. Please click on the ribbons as suggested to learn a little more about each one and then try the questions below.

Further feedback for question above:

Any condition which causes diplopia and visual loss can present with squints or head tilt as the child tries to compensate. This can either be due to localised disease as seen in retinoblastoma, rhabdosarcoma, optic glioma or due to increased intracranial pressure affecting the 6th nerve as in medulloblastoma and again optic glioma. ALL can present with facial nerve palsy and a FBC should be done in children presenting with a Bell’s palsy.

This chart is an excellent guide to some of the red flags for childhood malignancy. Please spend some time looking at it:

Pyrexia and rash – Case Conclusion

In case Pyrexia and rash

The purpose of showing the previous 4 images is to show that by just looking at the rash in isolation it is very hard to make a diagnosis. You have to have a clear differential diagnosis list and work your way through this with your history, focused examination and investigations.

Always look at the pattern. Is it on the extensor surfaces, does it look like a slap etc?

Another important point of this case is to try and bring out health prevention. Make the most of any consultation to not only diagnose the current problem but also try and prevent problems in the future.

Many conditions if actioned early can significantly reduce morbity. Always ask a full dietary history, this can influence obesity, iron deficiency anaemia, constipation, future food aversions if not weaned. Are they on the appropriate supplements , can you prevent the morbidity associated with Vitamin D deficiency. Is their development appropriate, do they need referral to speech and language?

Finally in this case you will have been directed to some of the red flags in paediatric oncology. Children often cannot express the signs such as reduced vision, headaches as well as adults and therefore you need to be aware of the significance of other signs such as vomiting, not as playful, head tilting etc. Hopefully by early detection the child will have a much greater chance of a full recovery.

CASE COMPONENT

 Formative Assessment