Management of Fever and Rash in Children

Diagnostic Approach

The American Heart Association recommends that children with fever, rash, and swollen hands be evaluated for Kawasaki disease, with immediate echocardiography, laboratory testing, and urgent treatment with intravenous immunoglobulin (IVIG) 2 g/kg plus high-dose aspirin if diagnostic criteria are met, as delayed treatment beyond 10 days of fever onset significantly increases the risk of coronary artery aneurysms 1
The Centers for Disease Control and Prevention (CDC) suggests that the combination of fever, rash on trunk/arms, and swollen hands in a 2-year-old requires urgent consideration of Kawasaki disease, incomplete Kawasaki disease, Rocky Mountain Spotted Fever (RMSF), meningococcemia, and viral exanthems 1, 2, 3
The American Academy of Pediatrics recommends determining fever duration and pattern, as fever ≥5 days is a critical factor in diagnosing Kawasaki disease, and duration of fever is the most powerful predictor of coronary artery aneurysms 1

The American Heart Association recommends obtaining CBC with differential, ESR, CRP, comprehensive metabolic panel, urinalysis, and blood culture if Kawasaki disease is suspected 1, 4
The CDC suggests that if tick-borne disease is suspected, laboratory evaluation should include CBC, comprehensive metabolic panel, and acute serology for R. rickettsii, E. chaffeensis, A. phagocytophilum 2, 3, 4, 5

The American Heart Association recommends obtaining urgent echocardiography if Kawasaki disease is suspected, complete or incomplete, or if fever ≥5 days with 2-3 principal features 1
The American Society of Echocardiography suggests that echocardiographic findings supporting Kawasaki disease include coronary artery ectasia, lack of tapering, or perivascular brightness, decreased LV contractility, mitral regurgitation, and pericardial effusion 1

The American Heart Association recommends immediate treatment with IVIG 2 g/kg and high-dose aspirin if Kawasaki disease criteria are met, with treatment within 10 days of fever onset critical to prevent coronary artery aneurysms 1, 4
The CDC suggests that if tick-borne disease cannot be excluded, empiric doxycycline treatment is indicated, with dosing regardless of age, including children <8 years, for suspected RMSF 2, 3, 6

The American Heart Association recommends repeat echocardiography at 2 weeks and 6-8 weeks after treatment for confirmed or treated Kawasaki disease, with cardiology follow-up for risk stratification and continuation of low-dose aspirin until coronary arteries are confirmed normal 1
The American Academy of Pediatrics suggests that for other diagnoses, close follow-up within 24 hours is necessary if discharged, with clear return precautions for worsening symptoms and reassessment if fever persists beyond expected course 6