Fever and Petechiae

Fever and Petechiae: Excerpt from The 5-Minute Pediatric Consult

Evaline A. Alessandrini, MD, MSCE

Fever and Petechiae - BASICS

Fever and Petechiae - description

• Petechiae:
  • Small hemorrhages into the superficial layers of the skin
  • <3 mm in size
  • Manifest as a reddish purple, macular, nonblanching skin rash
• Purpura:
  • Larger skin hemorrhages
  • Purple
  • Often macular like petechiae but may be raised or tender

Fever and Petechiae - general prevention

• Vaccine recommendations:
  • All children should complete the Streptococcus pneumoniae and Haemophilus influenzae type B immunization series that begins at 2 months of age.
  • Routine childhood immunization with meningococcal vaccine is not recommended. Immunization is recommended for children ≥2 years who are high risk, defined as asplenic, and those with terminal complement deficiencies.
  • Practitioners should consider immunizing college students who will be living in a dormitory for the 1st time, given that their risk of invasive disease is higher.
• Chemoprophylaxis is recommended for close contacts of patients with meningococcal disease. Ideally, treatment with rifampin, ceftriaxone, or ciprofloxacin should begin within 24 hours.

Fever and Petechiae - epidemiology

• Although there are no strong epidemiologic data, the presentation of fever and petechiae is rare compared with the presentation of fever alone.
• A great majority of patients (between 70–80%) presenting with fever and petechiae have defined or presumed viral infections, which are most often caused by enterovirus or adenovirus.
• Several prospective studies have documented that between 2–15% of children presenting with fever and petechiae will have an invasive bacterial disease, most commonly Neisseria meningitides.
• Infants and toddlers are at greatest risk of having an invasive bacterial infection with fever and petechiae.
• Teenagers and young adults are most commonly affected by outbreaks of meningococcemia, presenting with fever and petechiae.
• Streptococcal pharyngitis may cause fever and petechiae in the well-appearing child.
• Other etiologies, such as acute leukemia, idiopathic thrombocytopenic purpura (ITP), and Henoch-Schönlein purpura (HSP) are responsible for between 5–10% of cases of fever and petechiae.

Fever and Petechiae - pathophysiology

Petechiae may result from several different mechanisms:

• Disruption of vascular integrity—owing to infections, vasculitis, or trauma
• Platelet deficiency or dysfunction—typically thrombocytopenia owing to sepsis, disseminated intravascular coagulation (DIC), ITP, or leukemia
• Factor deficiencies (more likely to manifest as ecchymoses and deep bleeding)

Fever and Petechiae - etiology

Petechiae, when accompanied by fever, most often have an infectious cause. Multiple organisms are associated with fever and petechiae. Less commonly, fever and petechiae may be caused by other entities, such as acute leukemia, ITP, and bacterial endocarditis.

• Bacterial:
  • N. meningitidis
  • S. pneumoniae
  • H. influenzae type B
  • Staphylococcus aureus
  • Streptococcus pyogenes
  • Escherichia coli
• Viral:
  • Enterovirus
  • Adenovirus
  • Influenza
  • Parainfluenza
  • Epstein-Barr virus (EBV)
  • Rubella
  • Respiratory syncytial virus
  • Hepatitis viruses
• Rickettsial diseases:
  • Rickettsia rickettsii
  • Ehrlichiosis

Fever and Petechiae - DIAGNOSIS

Fever and Petechiae - signs & symptoms

Fever and Petechiae - history

Important historical factors to obtain include:

• Age of the child
• Any underlying immunodeficiency
• Immunizations received
• Exposure to infectious contacts, particularly N. meningitidis
• Duration and height of fever
• Duration and progression of rash
• Excessive coughing or vomiting
• Pallor or other bleeding
• Level of activity, excess fatigue
• Travel or history of tick bites
• History of trauma in location of rash

Fever and Petechiae - physical exam

• Important components on which to concentrate:
  • Vital signs, particularly noting tachycardia or hypotension
  • Mental status
  • Meningismus/nuchal rigidity
  • Character of rash: Petechiae or purpura, body distribution, number of lesions, progression during exam
• Important findings suggesting specific diagnoses:
  • Pallor, adenopathy, organomegaly (suggesting leukemia, EBV infection)
  • Mucous membrane bleeding (suggesting thrombocytopenia, such as that which occurs in ITP)
  • Myalgias, centripetal rash distribution (suggesting Rocky Mountain spotted fever)

Fever and Petechiae - tests

Fever and Petechiae - lab

All children with fever and petechiae require laboratory testing. At a minimum, children should receive a CBC with differential and a blood culture.

• Children >12–18 months with fever and petechiae should have a throat culture.
• Children who are ill-appearing may warrant coagulation studies, including a prothrombin time (PT), partial thromboplastin time (PTT), and DIC screen.
• Viral testing, including cultures, serology, and antibody immunofluorescence, is not routinely required and may be ordered at the discretion of the managing practitioner based on exposures, need for specific therapeutic interventions, admission to the hospital, and severity of illness.
• Nontoxic-appearing children >2 years of age with fever and petechiae should have a CBC with differential, blood culture, PT, and PTT.
• Although no 1 factor is 100% sensitive in identifying children with invasive bacterial disease, a constellation of factors is useful in identifying children with fever and petechiae in whom invasive bacterial disease is unlikely:
  • Multiple studies have demonstrated that well-appearing children with a normal WBC count (between 5,000 and 15,000), a normal absolute neutrophil count (between 1,500 and 9,000), an absolute band count <500, and petechiae limited to above the nipple line are exceedingly unlikely to have an invasive bacterial infection.

Unsuspected invasive bacterial disease is the most common pitfall with fever and petechiae. A thorough history and physical exam, accompanied by laboratory testing and a period of close observation, may minimize missed serious diagnoses.

Fever and Petechiae - differencial diagnosis

• Viral infections (see “Etiology”)
• Invasive bacterial infections:
  • Most commonly N. meningitidis
  • Less often S. aureus, E. coli, S. pneumoniae, and H. influenzae type B. S. pneumoniae and H. influenzae type B are less common because of widespread childhood immunization.
• Streptococcal pharyngitis owing to S. pyogenes
• Rickettsial infections: Diagnosis aided by season, history of tick bite accompanied by fever, petechiae, headache, and myalgias
• Stress petechiae in the distribution of the superior vena cava (SVC) after significant coughing or vomiting
• Coining or other traumatic causes
• Acute leukemias: Diagnosis aided by clinical findings of pallor, adenopathy, and hepatosplenomegaly, and laboratory findings
• ITP: Diagnosis aided by findings of mucous membrane bleeding and isolated thrombocytopenia on laboratory testing
• HSP: Diagnosis aided by clinical findings consistent with HSP, including palpable purpura on the buttocks and lower extremities, usually in the absence of fever
• Endocarditis: Diagnosis aided by a history of congenital heart disease, cardiac surgery, or rheumatic fever

Fever and Petechiae - TREATMENT

Fever and Petechiae - initial stabilization

• The management of children who are ill-appearing and have meningismus or purpura consists of a full sepsis evaluation, admission to the hospital with parenteral antibiotics, and fluids and vasoactive infusions to maintain normal hemodynamics.
• Because sporadic as opposed to epidemic cases of meningococcemia appear to occur in children in the 1st 2 years of life, and these children have less competent immune systems in fighting encapsulated organisms, full sepsis evaluations and admission for all children in this young age group is recommended.
• The well-appearing child with fever and petechiae and a positive streptococcal antigen test may be treated as an outpatient with antistreptococcal antibiotics.
• After a several-hour period of observation, children who remain well-appearing, are not tachycardic, have no progression of petechiae, and have normal lab studies may be considered for management as outpatients.

Fever and Petechiae - medication

• Prudent antibiotic choices are those effective against meningococcal and streptococcal disease, including 3rd-generation cephalosporins such as cefotaxime and ceftriaxone.
• Doxycycline should be administered if rickettsial disease is considered.
• Vancomycin should be administered to children with suspected pneumococcal meningitis.
• Empiric antibiotic use should be decided on a case-by-case basis. There are no studies investigating the efficacy of antibiotic therapy in the outpatient management of patients with fever and petechiae. However, this author advocates use of parenteral ceftriaxone as N. meningitides, the most likely bacterial pathogen in this circumstance, has a high morbidity and mortality.

Fever and Petechiae - FOLLOW UP

Fever and Petechiae - prognosis

• Depends on the underlying cause
• As most cases of fever and petechiae are caused by viral infections, particularly enteroviruses and adenoviruses, the prognosis is excellent.
• Studies demonstrate that the mortality rate of meningococcemia is between 7–20%.

Fever and Petechiae - complications

• Related to the underlying cause
• Most common complications of invasive bacterial disease causing fever and petechiae include sepsis and meningitis.
• Morbidity from N. meningitides includes neurologic deficits, limb loss, and skin sloughing, necessitating skin grafts. Mortality is estimated to be between 7–20%.

Fever and Petechiae - patient monitoring

• Children managed as outpatients:
  • Give instructions to return immediately for progression of rash or worsening illness.
  • Follow up in 12–18 hours.
  • Monitor cultures closely.
• Most children with viral causes have little progression of their petechiae and are clinically better within several days with the resolution of fever.

Fever and Petechiae - bibliography

1. Mandl KD, Stack AM, Fleisher GR. Incidence of bacteremia in infants and children with fever and petechiae. J Pediatr. 1997;131:398–404.
2. Neilsen HE, Andersen EA, Andersen J, et al. Diagnostic assessment of haemorrhagic rash and fever. Arch Dis Child. 2001;85:160–165.
3. Wells LC, Smith JC, Weston VC, et al. The child with a non-blanching rash: How likely is meningococcal disease? Arch Dis Child. 2001;85:218–222.

Fever and Petechiae - CODES

• 082.0 Spotted fever; Rocky mountain spotted fever
• 780.6 Fever
• 782.7 Petechiae

Fever and Petechiae - FAQ

• Q: What is the most common cause of fever and petechiae in children?
• A: Viruses are the most common overall cause of fever and petechiae in children.

  The most common invasive bacterial disease causing fever and petechiae in children in the 21st century is N. meningitidis.

• Q: Is there ever a role for outpatient management of children with fever and petechiae?
• A: Practitioners may consider outpatient management in well-appearing children >2 years of age with all of the following criteria after a period of observation in which they have normal vital signs and no progression of petechiae:

  A normal WBC count (between 5,000 and 15,000)

  A normal absolute neutrophil count (between 1,500 and 9,000)

  An absolute band count <500

  Petechiae limited to above the nipple line

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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