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    This document presents a case involving an irritable child with fever, rashes, and conjunctivitis. Differentials discussed include Kawasaki disease, measles, scarlet fever, and roseola infantum. Kawasaki disease is considered the most likely diagnosis given the patient's symptoms of fever, rash, conjunctivitis and oral changes. While some symptoms overlap with measles or scarlet fever, factors such as rash distribution and absence of other classic signs make those less probable than Kawasaki disease.

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    PERTINENTS_DIFF-DX

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    This document presents a case involving an irritable child with fever, rashes, and conjunctivitis. Differentials discussed include Kawasaki disease, measles, scarlet fever, and roseola infantum. Kawasaki disease is considered the most likely diagnosis given the patient's symptoms of fever, rash, conjunctivitis and oral changes. While some symptoms overlap with measles or scarlet fever, factors such as rash distribution and absence of other classic signs make those less probable than Kawasaki disease.

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    © All Rights Reserved
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    35 views6 pages

    Differentials: Less Common Infections

    Uploaded by

    Taeyomi
    This document presents a case involving an irritable child with fever, rashes, and conjunctivitis. Differentials discussed include Kawasaki disease, measles, scarlet fever, and roseola infantum. Kawasaki disease is considered the most likely diagnosis given the patient's symptoms of fever, rash, conjunctivitis and oral changes. While some symptoms overlap with measles or scarlet fever, factors such as rash distribution and absence of other classic signs make those less probable than Kawasaki disease.

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    of 6

    POSITIVES NEGATIVES

     Age & gender  anicteric sclerae,


     Fever (highest 38.2)  (-) cervical lymphadenopathy,
     Irritable  no tonsillopharyngeal congestion /
     (+) nonpruritic maculopapular rashes neck vein engorgement
    on the trunk, back, and neck  distinct heart sounds, regular rhythm,
     Erythematous conjunctivae (-) murmurs
     dry, erythematous, cracking lips
     tachycardia
     (+) tenderness of the right ankle, (+)
    erythema of the palms and soles

    DIFFERENTIALS
    LESS COMMON INFECTIONS
    Rocky Mountain spotted fever and leptospirosis are occasionally confused with KD

    Rocky Mountain spotted

     distinguishing features include pronounced myalgias and headache at onset, centripedal rash,
    and petechiae on the palms and soles.

    Leptospirosis

     Risk factors include exposure to water contaminated with urine from infected animals.
     classic description of leptospirosis is of a biphasic illness with a few asymptomatic days between
    an initial period of fever and headache and a late phase with renal and hepatic failure.
     In contrast, patients with KD have consecutive days of fever at diagnosis and rarely have renal or
    hepatic failure Children with KD and pronounced myocarditis may demonstrate hypotension with
    a clinical picture similar to that of toxic shock syndrome.

    toxic shock syndrome

     (+)renal insufciency, coagulopathy, pancytopenia, and myositis.

    1ST

    SJS KD
    s/sx: s/sx
     periorbital edema, oral ulcerations, and  Fever is characteristically high (≥38.3°C
    a normal or minimally elevated ESR are [101°F]), unremitting, and unresponsive
    not seen in KD. to antibiotics.
     dysphagia and ocular pruritus, followed  conjunctivitis
    by high fever, respiratory symptoms and  erythema of the oral and pharyngeal
    rashes with blisters or lesions causing mucosa with strawberry tongue and red,
    mucosal inflammations. cracked lips; edema and erythema of the
     Skin lesions are usually preceded by a hands and feet;
    few days by inflammation and dryness of  rash of various forms (maculopapular,
    the mouth and genitalia. erythema multiforme, or scarlatiniform);
     The oral, ocular and genital mucous and nonsuppurative cervical
    membranes are gradually affected by lymphadenopathy, usually unilateral,
    erythema, erosion, and with node size >1.5 cm
    pseudomembranes.  Perineal desquamation is common in the
     Patients are severely ill and bullous acute phase.
    lesions develop fast both on skin and  Periungual desquamation of the fngers
    mucous membranes (10), often within and toes begins 2-3 wk afer the onset of
    12 hours illness and may progress to involve the
    entire hand and foot

    RULE IN: RULE IN:


     FEVER  FEVER
     Oral lesions  Oral lesions
     Conjunctivitis  Conjunctivitis
     Rash  Rash

    Rule out: Rule out:


     SJS is casued by drug reaction  Unknown casue
     Rash- pruritic, painful and target in  Nonpruritic rash,
    appearance, visucular-bullae, starts polymorphous/morbiliform, starts
    from the face, spreads to whole bosy from the trunk spread to extremities
     Conjunctitivitis: exudative  Conjunctitivitis: non-exudative
     (+) nikolsky sign  (+) lymphadenopathy
     Perineal and periungual
    Desquamation
    Systemic onset juvenile idiopathic arthritis

     difuse lymphadenopathy and hepatosplenomegaly.


     Laboratory fndings may include coagulopathy, elevated fbrin degradation
    product values, and hyperferritinemia. Interestingly, there are reports of
    children with systemic-onset juvenile idiopathic arthritis
    2.) Measles, also known as rubeola, is a highly contagious viral disease. It remains an important
    cause of death among young children globally, despite the availability of a safe and effective
    vaccine.
    Measles virus is a single-stranded, lipid-enveloped RNA virus in the family Paramyxoviridae and
    genus Morbillivirus.

    Measles is transmitted via droplets from the nose, mouth or throat of infected persons.
    Patients are infectious from 3 days before to up to 4-6 days after the onset of rash.

    Initial symptoms, which usually appear 8–12 days after infection, include high fever, cough,
    coryza, conjunctivitis and Koplik spots or tiny white spots on the inside of the mouth, which is a
    pathognomonic sign of measles, appearing 1-4 days prior to the onset of the rash. Several days
    later, a rash develops, starting on the forehead (around the hairline), behind the ears, and on
    the upper neck as a red maculopapular eruption. It then spreads downward to the torso and
    extremities, reaching the palms and soles in up to 50% of cases. The exanthem frequently
    becomes confluent on the face and upper trunk.

    This was ruled-in due to the presence of fever, maculopapular rash and erythematous
    conjunctivae in the patient.

    However, this can be ruled-out since the distribution of rash on this patient started on the trunk
    and abdomen(while in the case of measles, it would start in the forehead down to the trunk
    and extremities), cough and coryza or runny nose were absent which are classic symptoms of
    measles along with conjunctivitis, no Koplik spots which is a pathognomonic sign (seen in 50-
    70% of measles patients), also in this patient, the fever persisted for several days, while in
    measles usually, symptoms would subside with the onset of rash.

    3.) Scarlet Fever


    Definiton
    Scarlet fever is an upper respiratory tract infection associated with a characteristic
    rash, which is caused by an infection with pyrogenic exotoxin (erythrogenic toxin)–
    producing GAS in individuals who do not have antitoxin antibodies. It is now encountered
    less commonly and is less virulent than in the past, but the incidence is cyclic, depending on
    the prevalence of toxin-producing strains and the immune status of the population.
    Etiology
    Group A streptococcus (GAS), also known as Streptococcus pyogenes, is a very
    common cause of infections of the upper respiratory tract (pharyngitis) and the skin
    (impetigo, pyoderma) in children and less frequently causes perianal cellulitis, vaginitis,
    septicemia, pneumonia, endocarditis, pericarditis, osteomyelitis, suppurative arthritis, myositis,
    cellulitis, and omphalitis.
    Group A streptococci are Gram-positive coccoid-shaped bacteria that tend to grow in
    chains. They are broadly classified by their hemolytic activity on mammalian (typically
    sheep) red blood cells.

    Rule in
    Fever

    Skin lesion
    Swollen neck glands

    Rule out
    Fever unresponsive to antipyretics
    no tonsillopharyngeal congestion
    unremarkable tongue on pe
    no erythema on axilla, elbow and groins

    4.) ROSEOLA INFANTUM Differential Diagnosis


    Definition:
    Roseola is a generally mild infection that usually affects children by age <3 years old. Human
    herpesvirus 6 (HHV-6A and HHV-6B) and human herpesvirus 7 (HHV-7) cause ubiquitous
    infection in infancy and early childhood. HHV-6B is responsible for the majority of cases of
    roseola infantum (exanthem subitum or sixth disease) and is associated with other diseases,
    including encephalitis, especially in immunocompromised hosts. A small percentage of children
    with roseola have primary infection with HHV-7.
    ETIOLOGY:
    HHV-6A, HHV-6B, and HHV-7 are the sole members of the Roseolovirus genus in the
    Betaherpesvirinae subfamily of human herpesviruses.
    EPIDEMIOLOGY:
    Primary infection with HHV-6B is acquired rapidly by essentially all children following the loss of
    maternal antibodies in the 1st few mo of infancy, 95% of children being infected with HHV-6 by
    2 yr of age. The peak age of primary HHV-6B infection is 6-9 mo of life, with infections occurring
    sporadically and without seasonal predilection or contact with other ill individuals.

    PATHOGENESIS
    Human herpesvirus 6 replicates most commonly in the leukocytes and the salivary glands
    during the primary infection and will, therefore, be present in saliva. Early invasion of the
    central nervous system (CNS) has also been shown.

    CLINICAL MANIFESTATIONS

     Fever (3-5 days) with fussiness


     Rash within 12-24h of fever resolution: discrete, small pink lesions on trunk, spreads in
    centripetal pattern, fades in 1-3 days
     Ulcers in uvulopalatoglossal junction (Nagayama spots)
     Bulging anterior fontanelle
     Convulsions
    LABORATORY FINDINGS

     lower mean numbers of total white blood cells (8,900/μL), lymphocytes (3,400/μL), and
    neutrophils (4,500/μL)
     Thrombocytopenia, elevated serum transaminase values, and atypical lymphocytes have
    also been noted sporadically in children with primary HHV-6B infection
     CSF analyses reported in patients with encephalitis thought to be caused by HHV-6 have
    been normal or demonstrated only minimal CSF pleocytosis with mild elevations of
    protein
    DIAGNOSIS

     HHV-6 serology, PCR, virus culture


     Low WBC count, neutrophils, lymphocytes
    RULE IN

     Fever
     Rash: maculopapular lesions on trunk and abdomen
     Irritability
    RULE OUT

     (-) Nagayama spots


     (-) Convulsions

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