Fever and Petechiae
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- Small hemorrhages (<3 mm in size) into the superficial layers of the skin
- Manifest as a reddish purple, macular, nonblanching skin rash
- Larger skin hemorrhages (>3 mm in size)
- Often macular like petechiae but may be raised or tender
- Most patients (70–80%) presenting with fever and petechiae have defined or presumed viral infections, which are often caused by enteroviruses or adenovirus.
- Parvovirus B19 may also be responsible for many cases of fever and generalized petechiae in children.
- Approximately 0.5–11% of children presenting with fever and petechiae will have an invasive bacterial disease, most commonly Neisseria meningitidis.
- 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 a minority of cases of fever and petechiae.
- 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 recommended for all children at 11–12 years of age and a booster dose at 16–18 years of age.
- Infants and children at high risk for meningococcal disease such as those with asplenia or terminal complement deficiencies should receive meningococcal vaccine as early as 2 months of age.
- Annual immunization against influenza viruses is recommended for all children >6 months of age.
- Chemoprophylaxis is recommended for close contacts of patients with meningococcal disease. Ideally, treatment should begin within 24 hours; rifampin is the drug of choice in most children (dosing <1 month of age: 5 mg/kg PO every 12 hours × 2 days, ≥1 month of age: 10 mg/kg PO every 12 hours × 2 days). Alternatives include ceftriaxone, ciprofloxacin, and azithromycin.
Petechiae may result from several different mechanisms:
- Disruption of vascular integrity—due to infections, vasculitis, or trauma
- Platelet deficiency or dysfunction—typically thrombocytopenia due to sepsis, disseminated intravascular coagulation (DIC), ITP, or leukemia
- Factor deficiencies, although these are more likely to manifest as ecchymoses or deep bleeding