Basics
Description
- Petechiae
- Small hemorrhages (<3 mm in size) into the superficial layers of the skin
- Manifest as a reddish purple, macular, nonblanching skin rash
- Purpura
- Larger skin hemorrhages (>3 mm in size)
- Often macular like petechiae but may be raised or tender
Epidemiology
- 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-Sch ¶nlein purpura (HSP), are responsible for a minority of cases of 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 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.
Pathophysiology
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
Diagnosis
Differential Diagnosis
- Viral infections (see "Etiology"ť)
- Invasive bacterial infections
- Most commonly N. meningitidis
- Less often Staphylococcus aureus or other bacteria (see "Etiology"ť)
- Streptococcal pharyngitis-due to Streptococcus pyogenes
- Rickettsial infections: diagnosis aided by season, history of tick bite accompanied by fever, petechiae, headache, and myalgias
- Petechiae above the nipple line may be noted after significant coughing or vomiting.
- Coining or other traumatic causes
- Acute leukemias: diagnosis aided by clinical findings of pallor, adenopathy, 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 dependent areas such as the buttocks and lower extremities, often without fever
- Endocarditis: diagnosis aided by bacteremia and a history of congenital heart disease, cardiac surgery, or rheumatic fever
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, HSP, and bacterial endocarditis.
- Bacterial
- N. meningitidis
- S. pneumoniae
- H. influenzae type B
- S. aureus
- S. pyogenes
- Escherichia coli
- Viral
- Enterovirus
- Adenovirus
- Influenza
- Parainfluenza
- Parvovirus B19
- Epstein-Barr virus (EBV)
- Rubella
- Respiratory syncytial virus
- Hepatitis viruses
- Rickettsial diseases
- Rickettsia rickettsii
- Ehrlichiosis
Alert
Unsuspected invasive bacterial disease is the most common pitfall in the differential diagnosis of fever and petechiae. A thorough history and physical exam accompanied by laboratory testing, a period of close observation, and empiric antimicrobial therapy may minimize missed serious diagnoses.
History
Important historical factors to obtain include the following:
- 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
Physical Exam
- Important components of exam:
- Vital signs, noting tachycardia, hypotension, or delayed capillary refill
- Mental status
- Meningismus/nuchal rigidity
- Character of rash: petechiae or purpura, body distribution, number of lesions, progression during exam
- Important findings suggesting specific diagnoses:
- Finding: Pallor, adenopathy, organomegaly
- Significance: May suggest leukemia, EBV infection
- Finding: Mucous membrane bleeding
- Significance: May suggest thrombocytopenia, such as with ITP
- Finding: Headache, myalgias, centripetal rash distribution
- Significance: May suggest Rocky Mountain spotted fever
Diagnostic Tests & Interpretation
Most children with fever and petechiae require laboratory testing. Consider obtaining a CBC with differential, C-reactive protein (CRP), and a blood culture even in non-toxic-appearing children.
- Consider rapid antigen testing for group A Streptococcus and throat culture if with signs of pharyngitis.
- Children who are ill-appearing may warrant lumbar puncture for cerebrospinal fluid (CSF) studies and coagulation studies including 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.
- Although no one 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 cells/microliter), a normal absolute neutrophil count (between 1,500 and 9,000 cells/microliter), an absolute band count <500 cells/microliter, and petechiae limited to above the nipple line are exceedingly unlikely to have an invasive bacterial infection. A CRP <6 mg/L has also been shown to have a high negative predictive value for ruling out invasive bacterial infection.
Treatment
Medication
- Empiric antibiotic use should be decided on a case-by-case basis. Due to the high morbidity and mortality of N. meningitidis, the most likely bacterial pathogen in this circumstance, empiric ceftriaxone should be strongly considered in children with fever and petechiae who are not at low risk for bacterial infection.
- 3rd-generation cephalosporins such as ceftriaxone and cefotaxime are effective against most bacterial pathogens causing fever and petechiae.
- Doxycycline should be administered if rickettsial disease is considered.
- Vancomycin should be added to the regimen for children with suspected bacterial meningitis to cover penicillin and cephalosporin-resistant strains of S. pneumoniae.
Inpatient Considerations
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 first 2 years of life, and these children have less competent immune systems in fighting encapsulated organisms, full sepsis evaluation and admission for all children in this young age group are recommended.
- The well-appearing child with fever and petechiae and a positive streptococcal antigen test and an illness compatible with streptococcal pharyngitis 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.
Ongoing Care
Follow-up Recommendations
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.
Prognosis
- Depends on the underlying cause
- Because most cases of fever and petechiae are caused by viral infections, particularly enteroviruses and adenovirus, the prognosis is excellent.
- Case fatality rate of meningococcemia is 10-14%.
Complications
- Related to the underlying cause
- Most common complications of invasive bacterial disease causing fever and petechiae include sepsis and meningitis.
- Serious sequelae from N. meningitidis occur in 11-19% of patients and include neurologic deficits such as hearing loss, digit or limb loss, and skin scarring.
Additional Reading
- Brayer AF, Humiston SG. Invasive meningococcal disease in childhood. Pediatr Rev. 2011;32(4):152-161. [View Abstract]
- Klinkhammer MD, Colletti JE. Pediatric myth: fever and petechiae. CJEM. 2008;10(5):479-482. [View Abstract]
- 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(3):218-222. [View Abstract]
Codes
ICD09
- 780.6 Fever, unspecified
- 782.7 Spontaneous ecchymoses
- 287.2 Other nonthrombocytopenic purpuras
ICD10
- R50.9 Fever, unspecified
- R23.3 Spontaneous ecchymoses
- D69.2 Other nonthrombocytopenic purpura
SNOMED
- 386661006 fever (finding)
- 271813007 Petechiae (disorder)
- 423902002 purpura (finding)
FAQ
- Q: What are the most common causes 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 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 the following criteria after a period of close observation in which they have normal vital signs and no progression of petechiae:
- A normal WBC count (between 5,000 and 15,000 cells/microliter)
- A normal absolute neutrophil count (between 1,500 and 9,000 cells/microliter)
- An absolute band count <500 cells/microliter
- A CRP <6 mg/L