In Febrile Children Presenting to the ED, Watch Out for This Sign

Fever with petechial rash is an important warning sign in sick children, according to a multicenter European study published in Acta Paediatrica.¹

Although most children who present to emergency departments with febrile illness accompanied by petechial rash do not progress to a serious illness, a small number of patients have a severe underlying bacterial infection that needs urgent treatment. Identifying these patients is crucial for getting them appropriate care. Accordingly, European guidelines err on the side of caution, resulting in a large number of children receiving unnecessary treatment. Therefore, investigators sought to determine the diagnostic value of petechial rash and symptoms of coughing/vomiting in febrile children. 

A Management and Outcome of Fever in Children in Europe study

This prospective observational study formed part of the Management and Outcome of Fever in Children in Europe and recruited participants from 12 European emergency departments across eight countries from January 2017 to April 2018. Patients aged 0-18 years, with a temperature of 38°C or greater or a documented fever 72 hours prior to admission were included. Patients who did not have documentation of rash status were excluded. 

The cohort comprised 34,010 febrile patients, of which 453 (1.3%) had a petechial rash. A majority of the petechial rash cohort had coughing (58.9%) and/or vomiting (48.0%). In the petechial rash group, 3.1% of children had meningitis, and 2.2% had sepsis. The main outcome measure of the study was to investigate if the petechial rash had utility in identifying febrile children with bacterial infections, sepsis, and meningitis. Secondarily, the authors investigated if coughing/vomiting symptoms have utility in discerning those at risk of serious bacterial illness.

Petechial rash is a warning sign

Overall, febrile patients with petechial rash were more likely to have sepsis or meningitis (OR 8.5, 95% CI 5.3–13.1; P<.001) and bacterial infections (OR 1.4, 95% CI 1.0–1.8; P=.023) than the larger group of febrile children. Additionally, children with a petechial rash had a higher risk of being admitted to the intensive care unit (OR 6.5, 95% CI 3.0–12.5; P<.001) and needing immediate life-saving interventions (OR 6.6, 95% CI 4.4–9.5; P<.001). 

For the analysis of clinical signs of coughing and/or vomiting, 411 patients were included. The investigators found that coughing and/or vomiting was common in patients with petechial rash (79.6%), with comparable rates between those with sepsis/meningitis (73.9%) and other causes of illness (79.9%), as well as between bacterial infection (78.7%) and non-bacterial infection (79.9%). 

“We concluded that clinical appearance was not an indisputable way to exclude sepsis or meningitis in all patients,” the authors wrote. “Furthermore, appearing ill was not a suitable way of discriminating bacterial infections from other causes of infection.”¹

Clinical implications

The authors note that these results confirm petechial rashes are of diagnostic value in febrile children, while coughing/vomiting are not. “Our results show that fever and petechial rashes are still essential warning signs associated with higher rates of sepsis and meningitis than in other febrile children. Rates of vomiting and/or coughing were similar in patients with sepsis, meningitis, and other febrile causes and did not qualify as a discriminative marker,” they wrote.¹

While the study had many strengths (including its multicenter, prospective nature, size, and a cohort that represents the general population), the investigators do note some limitations. The study lacked data on return visits, as well as individual immunization status. They also lacked specific information about the petechial rashes including size, location, and progression. Lastly, vaccination strategies and clinical guidelines differed among countries that took part in the study.

Published: May 18, 2023