Primary care

10-minute consultation BMJ: first published as 10.1136/bmj.329.7468.719 on 23 September 2004. Downloaded from Morbilliform rash Caroline Furness, Rita Sharma, Anthony Harnden

This is part of A 2 year old boy presents with a three day history of Useful reading fever and morbilliform rash. His parents are worried a series of about the possibility of meningitis. Ramsay M, Reacher M, O’Flynn C, Buttery R, occasional Hadden F, Cohen B, et al. Causes of morbilliform articles on common What issues you should cover rash in a highly immunised English population. Arch Dis Child 2002;87:202-6 problems in Address the parents’ concerns about meningitis—A non- primary care blanching rash may be a crucial sign, but in the evolv- Granier S, Owen P, Pill R, Jacobson L. Recognising meningococcal disease in primary care: qualitative ing stages of meningococcal disease the rash may be Green College, blanching and maculopapular. Other important study of how general practitioners process clinical Oxford OX2 6HG features in recognising meningococcal disease are and contextual information. BMJ 1998;316:276-9 Caroline Furness poor eye contact, irritability, lethargy and lack of inter- medical student est, vomiting, stiffness in the neck (though this may not Department of globulin to prevent serious complications such as Primary Health be seen in infants), pallor, tachycardia, and prolonged Care, Institute of capillary refill. coronary artery aneurysms. Health Sciences, History of symptoms—Ask about the duration and height x Meningococcal infection, measles, rubella, and scar- OX3 7LF of the fever and the sequence of fever and rash devel- let fever are notifiable diseases. If you suspect either Rita Sharma measles or rubella, arrange for saliva samples for anti- clinical lecturer opment. A rash that appears as the fever resolves is Anthony Harnden typical of roseola infantum. In erythema infectiosum body tests to be taken two to three weeks after the onset university lecturer of the rash. Salivary kits may be obtained from the local “slapped cheeks” and a lace-like rash may occur up to a Correspondence to: week after fever. consultant in communicable disease control. A Harnden x Advise the parents that he should not go to nursery anthony.harnden@ Vaccination history—Having had a measles, mumps, and dphpc.ox.ac.uk rubella (MMR) vaccination makes a diagnosis of or playgroup until he is well. x If you suspect measles, look for signs of secondary The series is edited measles or rubella less likely but does not exclude it. by general The rash may be due to a recent MMR vaccination. complications such as pneumonia. practitioners Ann Contact history—Is there a history of recent contact with x If group A streptococcus is the clinical diagnosis, McPherson and take a throat swab. Deborah Waller another child with a fever or rash? Which infectious (ann.mcpherson@ x If he has been in close contact with a pregnant dphpc.ox.ac.uk)

diseases are common in the local community? Local http://www.bmj.com/ woman, contact your local laboratory and ask them to and national surveillance information may help in The BMJ welcomes making a diagnosis. Ask about any close contact with a check serum IgG concentrations for rubella and contributions from parvovirus B19. More than 98% of children vaccinated general pregnant woman. Rubella and parvovirus B19 (which practitioners to the causes erythema infectiosum) may damage an unborn against rubella are immune, and 60% have developed series child. Enteroviruses and adenoviruses (respiratory immunity to parvovirus B19 through exposure at some infection) are other viral causes of rashes. Also take a time in the past. If serology is negative the pregnant BMJ 2004;329:719 travel history and consider relevant diseases. Measles is woman should see an obstetrician. Early intervention for parvovirus induced hydrops foetalis may be critical. endemic in many parts of the developing world. Medi- on 30 September 2021 by guest. Protected copyright. terranean spotted fever leads to fever, rash, and a x Effective communication with the parents is necrotic area (eschar) at the site of the tick bite. essential if you think the boy has a self limiting illness. Indicative clinical signs—Specific features on examina- Explain the importance of fluid maintenance and rec- tion make particular diagnoses more certain: Koplick’s ommend antipyretic drugs. Tell the parents that you spots indicate measles; post-auricular and suboccipital are happy to review his case if any deterioration occurs lymphadenopathy indicate rubella; and strawberry or within 72 hours if no signs of clinical improvement tongue and circumoral pallor indicate scarlet fever. are shown. Consider Kawasaki disease—Aside from rash and fever, signs of Kawasaki disease include non-purulent con- junctival injection, changes in peripheral extremities, A list of diseases and their typical clinical features is on bmj.com oral mucosal changes, and cervical lymphadenopathy.

What you should do Endpiece x If you suspect meningococcal disease treat the boy Your duty with intravenous or intramuscular penicillin (infant 300 mg, 1 to 9 years 600 mg, over 10 years 1.2 g). If it is You are here to enable the divine purpose of the universe to unfold. That is how important you are! available, chloramphenicol may be used if he has a his- tory of penicillin anaphylaxis. The critical action is to Tolle E. The power of now. refer him immediately to hospital. London: Hodder and Stoughton, 2001 x If you suspect Kawasaki disease, refer him urgently Allan Withnell retired area medical officer, Gloucester for treatment with aspirin and intravenous immuno-

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