Fever, Rash and Joint Pain

Dear Lisa,

A 13yr old male presents with joint pain, intermittent temp. of 103 degrees, rash that comes and goes, lethargy and loss of appetite. Lab tests for infections diseases and cancers are negative. Besides juvenile arthritis, what other causes should be considered?

“What other causes should be considered?”

Dear “What other causes should be considered?”,

The most likely cause of a fever, rash and joint pain in a 13 year old male is a virus or a strep infection. Viruses such as Echoviruses, EBV, CMV, and Parvovirus commonly present with these symptoms. Since the work-up to rule out an infectious cause of this boy’s symptoms was negative, my first inclination would be to redo the throat culture for strep pharyngitis. It is not infrequent that a child presents with a similar scenario and an elaborate work-up is performed only to come up with negative results. It turns out that many times the cause is something common such as a virus or a strep infection. Sometimes an initial throat culture for strep pharyngitis is negative because the technique used to obtain the throat swab did not result in a good specimen. Sometimes the strep test is performed early on in the course of the illness, during the incubation period when it is too soon to show a positive results on a test. If a repeat strep test returns negative, then further investigation into other causes for the symptoms is warranted.

The initial evaluation for infectious diseases typically includes the most likely culprits. When all of the testing comes back negative and a child’s symptoms persist an investigation into diseases with a lower index of suspicion need to be investigated. Tick borne diseases many times present with fever, rashes and arthralgias and should be considered in this case. Tick borne illnesses including Lyme Disease, Rocky Mountain Spotted fever, Eehrlichiosis, human granulocytotropic or granulocytic anaplasmosis and Ehrlichia ewingii infections should all be ruled out. Many times these infections are not initially considered because the thought is that a child does not live in an area where the disease is most prevalent. It is interesting to note that all of these tick borne illnesses are found in the United States. (1,2)

Another reason tick borne illnesses are usually not considered is because there is no recollection of a tick bite. Just because a parent does not recall a tick bite, does not mean that tick borne illnesses should not be considered. It is not suprising that many patients and their parents do not remember a tick bite since the tick that transmits Lyme disease can be as small as a poppy seed, making it easy to miss. (1,2)

In the acute stage of Lymes Disease symptoms may include headache, stiff neck, recurrent rashes, body aches, joint pain, fever and tender lymph nodes. (2) Although cases of Lyme Disease have been reported in every state (2), most cases of Lyme disease occur in the Northeast from southern Maine to northern Virginia. (3) Symptoms of Rocky Mountain Spotted Fever include fever, headache, myalgia(pain in the muscles), rash, confusion, nausea, vomiting and anorexia (loss of appetite). All of the states in America have reported cases of Rocky Mountain Spotted fever except for Maine and Vermont.

Sexually transmitted diseases are another consideration in an adolescent child with fever, rash and arthralgia. This may sound absurd to some, because of the child’s young age. Before the notion is dismissed it is important to know that it has been reported that many children become sexually active during middle and late adolescence. (4) Upon interviewing adolescents and teenagers about sexual activity many of them do not consider oral sex as sexual activity or they consider oral sex “safe sex” and therefore don’t report it. (5) Other adolescents may not disclose their sexual history because of fear that their parents will find out. (6) It would be prudent to gain the child’s trust and obtain a thorough sexual history to ascertain if the child is at risk.

Oral sex can lead to Gonoccocal phyaryngitis which presents as a fever, sore throat, and/or cervical lymphadenopathy. Gonococcal pharyngitis predisposes the patient to disseminated gonorrhea. Signs of disseminated gonorrhea include monoarticular septic arthritis or arthritis/dermatitis syndrome. The arthritis/dermatitis syndrome of disseminated Gonococcal infection classically presents with dermatitis, tenosynovitis and migratory polyarthritis. (7)

The incidence of Syphilis has risen since the year 2000. (8) Secondary syphilis typically manifests 4 to 8 weeks after the infective exposure. The symptoms include arthralgias, headache, nausea, fever and fatigue. Almost all patients have skin lesions as well as generalized hard, discrete, non-tender adenopathy. The earliest expression of secondary syphilis is very often a mild erythematous eruption involving the trunk, neck, and upper arms. (8)

Autoimmune diseases such as Juvenile Arthritis may also present with high fever, rashes and arthralgias. Intermittent high fevers (103 degrees Fahrenheit or higher) with or without rash or other organ involvement is characteristic of systemic–onset Juvenille Arthritis. The age of onset typically occurs between 2 and 16 years old. In addition to fever and rash, other systemic manifestations are common and include pleuritis(inflammation of the membrane that encloses the lungs), pericarditis(inflammation of the lining around the heart), leukocytosis(elevated white blood count) and anemia. These symptoms may occur over a period of months and fluctuate through periods of remissions and exacerbations.

A child with persistent symptoms of fever, rash and arthralgias can benefit from consultations with specialists in order to make or monitor a diagnosis. An Infectious Disease Specialist investigates infectious causes for a child’s symptoms. A Pediatric Rheumatologist’s area of expertise is childhood inflammatory and autoimmune diseases. A consult with a Pediatric Rheumatologist is commonly made when all other causes of a fever in a child have been exhausted. Since inflammatory diseases have mutli-organ involvement, many of them including the eyes, a Pediatric Ophthalmologist may also be consulted. Changes in the ophthalmologic examination can give the team of specialist clues to the type of inflammatory or autoimmune disease that the child has. In a variety of rheumatologic disease , the discovery of uveitis might be the first clue to the underlying condition. (9)

As always a detailed family history, patient history and social history along with a complete physical examination is necessary in order to best ascertain the source of a child’s fever. Information such as recent travel, exposure to animals or communicable diseases and past history of recurrent fevers are all pieces of clinical information that are necessary in order to make a proper diagnosis.

(1)CDC develops guidelines for tickborne diseases. Infectious Diseases in Children. 2006;May:18.
(2)Savely G. Update on Lyme Disease. Clinicians Reviews. 2006;April:45-50.
(3) Fantausch B, Rassbach C. Reviewing Lyme disease with facial palsy and meningitis. Infectious Diseases in Children. 2006;Feb:86-87.
(4)Fortenberry JD. Clinic-based service programs for increasing responsible sexual behavior J Sex Res. 2002;39(1):63-66.
(5)Reitman D. Update on Sexually Transmitted Diseases: Gonorrhea and Chlamydial Infections. Consultant for Pediatricians. 2006; March: 155-158.
(6) Grimshaw-Mulcahy L. Chlamydia: Diagnosing the hidden STD. The Clinical Advisor. 2006; March:32-42.
(7)Guinto-Ocampo H, Friedland LR. Disseminated gonococcal infection in three adolescents. Pediatr Emerg Care. 2001;17(6):441-443.
(8)Burkhart C. Dermatology Clinic. Syphilis. The Clinical Advisor. 2006;April. 66.
(9)Listernick R. An 11-month old Boy with Recurrent Fever. Pediatric Annals.2005;34(10):764-771.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents with Sick Children