Published online December 1, 2006
PEDIATRICS Vol. 118 No. 6 December 2006, pp. 2450-2460 (doi:10.1542/peds.2006-1515)
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ARTICLE

Clinical Deterioration Among Patients With Fever and Erythroderma

Robyn L. Byer, MD and Richard G. Bachur, MD

Division of Emergency Medicine, Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts

BACKGROUND. Some children who present with fever and erythroderma have rapid clinical deterioration or progress to toxic shock syndrome. Our primary objective was to determine whether specific clinical features of those who present with fever and erythroderma can predict who will develop hypotension or progress to toxic shock syndrome. Our secondary objective was to describe the clinical presentation, course, and outcome of children with fever and erythroderma.

METHODS. We conducted a medical chart review of children ≤19 years of age with fever and erythroderma who presented to an urban pediatric emergency department over 60 months. Historical, clinical, and laboratory data were abstracted from the medical chart.

RESULTS. Fifty-six patients with fever and erythroderma were studied. Eighteen percent of patients presented with hypotension. Thirty-three percent of the remaining patients who were normotensive on arrival developed shock. Fifty-two percent of patients with hypotension required vasopressor support. The most important predictors of developing hypotension after presentation were: age ≥3 years, ill appearance, vomiting, glucose ≥110 mg/dL, calcium ≤8.6 mg/dL, platelets ≤300000/µL, elevated creatinine, polymorphonuclear leukocytes ≥80%, and presence of a focal infection. Among all patients studied, 4 variables were determined to be the most important predictors of developing toxic shock syndrome: age ≥3 years, ill appearance, elevated creatinine, and hypotension on arrival.

CONCLUSIONS. Overall, 45% of patients with fever and erythroderma developed shock, including 33% of those who were normotensive on presentation. Older age, presence of vomiting, identification of a focal bacterial source, as well as specific laboratory parameters can be used to help predict which patients are likely to have hemodynamic deterioration. Given the high rate of clinical decompensation, all of the patients with fever and erythroderma should be hospitalized, closely monitored, and managed aggressively.

Key Words: erythroderma • fever • toxic shock syndrome • Staphylococcus aureus • Streptococcus pyogenes

Abbreviations: TSS—toxic shock syndrome • CDC—Centers for Disease Control and Prevention • ED—emergency department • CI—confidence interval • IQR—interquartile range • s/p—status post • BUN—blood urea nitrogen • ALT—alanine aminotransferase • PMN—polymorphonuclear leukocyte

Accepted Aug 16, 2006.