Diagnostic reasoning case · WHO IMCI and Pocket book of hospital care for children

Fever and rash in a child

During a measles outbreak every child with fever and a rash looks like another measles case. Most are. The skill is to check every child for the few signs that point elsewhere: a child who is drowsy, and a rash that does not fade when you press it.

  • Setting: Primary health care centre in an area with no malaria, during a measles outbreak
  • For nurses, clinical officers, doctors and community health workers trained in IMCI
  • Reviewed October 2026

The presentation

Sara, 4 years old, has had fever since last night. This morning her mother saw spots on her legs and tummy. There are measles cases in the neighbourhood. Sara has vomited twice and 'just wants to sleep'. She weighs 15 kg.

Taken at triage.
SignValue
Axillary temperature39.6 °C
Breathing rate34 per minute
Pulse156 per minute
Capillary refill3 seconds, hands cool
Conscious level (AVPU)Opens her eyes to voice, then drifts off
Weight15 kg

Tests at hand: Blood glucose (finger-prick) · Haemoglobin (Hb) · Pulse oximetry (SpO2)

Starting differential
  • MeaslesLeading
  • Meningococcal disease (meningitis or septicaemia) Must not missStill possible
  • Other septicaemia Must not missStill possible
  • Severe complicated measles Must not missStill possible
  • Other viral rashStill possible
  • Dengue or another haemorrhagic feverLess likely
  • Drug reactionLess likely

Work through it

Read each question and decide your own answer first. Then open the model answer and see how the differential changes.

  1. Step 1 of 6 · Look

    Before you look at the rash: is Sara an emergency? What do the triage findings tell you?

    Model answer
    • Emergency signs: obstructed breathing, severe respiratory distress, central cyanosis, shock (cold hands, capillary refill longer than 3 seconds, fast weak pulse), coma, convulsions.
    • General danger signs: not able to drink, vomits everything, convulsions, lethargic or unconscious.

    Sara is breathing without difficulty. Her hands are cool, capillary refill is 3 seconds and her pulse is fast: she is close to shock and must be checked again every few minutes. She opens her eyes only to voice and drifts back to sleep: that is lethargic, a general danger sign. She is seen now, ahead of the queue.

    A lethargic child with fever has very severe febrile disease until proved otherwise. Do the rest of the assessment quickly, without delaying treatment.
    Differential now
    • MeaslesLeading
    • Meningococcal disease (meningitis or septicaemia) Must not missLeading (moved up)
    • Other septicaemia Must not missLeading (moved up)
    • Severe complicated measles Must not missStill possible
    • Other viral rashLess likely (moved down)
    • Dengue or another haemorrhagic feverLess likely
    • Drug reactionLess likely
  2. Step 2 of 6 · Look

    Now the rash. How do you tell whether this is measles, and what else do you do with the rash?

    Model answer
    • Measles (IMCI): a generalised rash with at least one of cough, runny nose or red eyes. The rash of measles is maculopapular (flat red spots and small bumps), spreading from the head and upper body down.
    • Press on the spots with a finger or the side of a clear glass. Spots that do not fade (non-blanching), small pinpoint red-purple spots (petechiae) or larger purple bruises (purpura) suggest meningococcal disease, septicaemia or a haemorrhagic fever.
    • Look for a stiff neck, mouth ulcers, clouding of the cornea and pus from the eyes.

    The spots on her legs and abdomen are dark red and purple, a few millimetres across, and some have joined into a bruise on her thigh. They do not fade under a glass. She has no cough, no runny nose and her eyes are not red. Her neck is stiff when you try to bend it forward. No mouth ulcers.

    Differential now
    • Meningococcal disease (meningitis or septicaemia) Must not missLeading
    • Other septicaemia Must not missLeading
    • MeaslesLess likely (moved down)
    • Dengue or another haemorrhagic feverLess likely
    • Severe complicated measles Must not missSet aside for now (moved down)
    • Other viral rashSet aside for now (moved down)
    • Drug reactionSet aside for now (moved down)
  3. Step 3 of 6 · Ask

    What do you ask, quickly, while you prepare treatment?

    Model answer
    • When did the fever and the rash start, and how fast is the rash spreading?
    • Fits, headache, neck pain, light hurting the eyes?
    • Any medicine taken before the rash? (drug reaction)
    • Bleeding from the nose or gums, black stool, travel to an area with dengue?
    • Immunisations: measles, and meningococcal vaccine where it is given.
    • Anyone at home or school ill with fever and a rash, or a known meningitis case nearby?

    Fever started last night, the spots this morning and they are spreading. She complained of a headache and her neck hurting. No medicines except paracetamol, no bleeding, no travel. She has had both doses of measles vaccine. No other sick contacts known.

    Differential now
    • Meningococcal disease (meningitis or septicaemia) Must not missLeading
    • Other septicaemia Must not missLeading
    • MeaslesSet aside for now (moved down)
    • Severe complicated measles Must not missSet aside for now
    • Other viral rashSet aside for now
    • Dengue or another haemorrhagic feverSet aside for now (moved down)
    • Drug reactionSet aside for now
  4. Step 4 of 6 · Test

    You have glucose, haemoglobin and a pulse oximeter. Which do you use, and must you wait for them?

    Model answer
    • Glucose: yes, she is lethargic and has vomited. Low is below 2.5 mmol/L; if you cannot measure it, treat as low sugar.
    • Pulse oximetry: yes, to guide oxygen.
    • Haemoglobin does not change what you do now.
    • No malaria test is needed: there is no malaria here and she has not travelled. In a malaria area, test, or give pre-referral artesunate as well.
    • Do not wait for any result before giving the first antibiotic dose.

    Results: glucose 4.1 mmol/L. SpO2 96%.

    Differential now
    • Meningococcal disease (meningitis or septicaemia) Must not missLeading
    • Other septicaemia Must not missLess likely (moved down)
    • MeaslesSet aside for now
    • Severe complicated measles Must not missSet aside for now
    • Other viral rashSet aside for now
    • Dengue or another haemorrhagic feverSet aside for now
    • Drug reactionSet aside for now
  5. Step 5 of 6 · Do

    Classify her. What do you give now, before she leaves?

    Model answer

    Fever with a general danger sign (lethargic) and a stiff neck: very severe febrile disease. With a spreading non-blanching rash, this is suspected meningococcal disease.

    • First dose of an appropriate antibiotic now, intramuscular: IMCI gives ampicillin 50 mg/kg with gentamicin 7.5 mg/kg; many national charts use ceftriaxone for suspected meningitis. Use your national chart.
    • Prevent low blood sugar: if she can swallow, milk or sugar water; if not, by nasogastric tube.
    • Paracetamol for the high fever.
    • Oxygen if SpO2 falls below 90% or she has respiratory distress.
    • Watch for shock: if capillary refill becomes longer than 3 seconds with a weak fast pulse, treat for shock per your emergency chart while transport is arranged.
    Differential now
    • Meningococcal disease (meningitis or septicaemia) Must not missLeading
    • Other septicaemia Must not missLess likely
    • MeaslesSet aside for now
    • Severe complicated measles Must not missSet aside for now
    • Other viral rashSet aside for now
    • Dengue or another haemorrhagic feverSet aside for now
    • Drug reactionSet aside for now
  6. Step 6 of 6 · Do

    How do you send her, and what else must happen at the health centre?

    Model answer
    • Refer urgently, with a health worker if possible, lying on her side, with the referral note: the time and dose of the antibiotic, the glucose result and the rash.
    • Recheck pulse, capillary refill and consciousness until she leaves; mark the edge of the rash to see whether it spreads.
    • Report suspected meningococcal disease to the district surveillance officer the same day.
    • Household and other close contacts: chemoprophylaxis only for close contacts, as decided by the district team. Tell the family to come at once if anyone else develops fever.
    • Use standard precautions and a mask while you examine and treat her.

    These spots and her sleepiness may mean a serious infection of the blood or around the brain. I have given her the first injection. She needs the hospital now. If anyone at home gets a fever in the next days, bring them straight away.

Must-not-miss conditions

ConditionCluesWhat to do at first-level care
Meningococcal diseaseFever with a petechial or purpuric rash that does not fade on pressure; stiff neck, lethargy, vomiting, signs of shock.First antibiotic dose immediately, prevent low sugar; refer urgently; report; close contacts per district advice.
Septic shockCold hands, capillary refill longer than 3 seconds, fast weak pulse, lethargy.Emergency treatment for shock, oxygen, first antibiotic dose; urgent transfer.
Severe complicated measlesMeasles with clouding of the cornea, deep or extensive mouth ulcers, a danger sign, pneumonia, stridor, severe dehydration or severe malnutrition.Vitamin A, first dose of antibiotic, tetracycline eye ointment if eye signs; refer urgently.
Dengue or another haemorrhagic feverBleeding from nose or gums, black stool, petechiae, abdominal pain, shock, in an area or outbreak where these occur.Isolate if a viral haemorrhagic fever is possible; careful fluids; refer and report.

Decision at first-level care

Sara has fever, lethargy, a stiff neck and a spreading non-blanching purpuric rash, with no cough, runny nose or red eyes: this is not measles. She has very severe febrile disease with suspected meningococcal infection and is close to shock. She gets a first antibiotic dose at once and is referred urgently; the case is reported.

Source: WHO IMCI chart booklet (2014); WHO Pocket book of hospital care for children (2013).

Treat here
  • Measles (generalised rash with cough, runny nose or red eyes) with no complication: vitamin A, feeding, home care, isolation advice.
  • Measles with pus from the eye or mouth ulcers: vitamin A, tetracycline eye ointment or gentian violet, review in 3 days.
Observe and review
  • Mild viral rash that fades on pressure in a well, alert child who is drinking: review in 2 days, sooner if worse.
  • Unsure whether spots blanch: press again with a glass, look in good light, and keep the child at the clinic until you are sure.
Refer (urgently, now)This patient
  • Any rash that does not fade on pressure, with fever.
  • Any general danger sign or stiff neck.
  • Severe complicated measles.
  • Bleeding, shock or signs of a haemorrhagic fever.

Key learning points

  • Measles is a generalised rash plus cough, runny nose or red eyes; without them, think again.
  • Press on every rash in a child with fever: spots that do not fade suggest meningococcal disease or septicaemia.
  • Lethargy is a general danger sign; a lethargic child with fever needs treatment and referral now.
  • Give the first antibiotic dose before transfer; never wait for a test result.
  • Report suspected meningococcal disease and measles to the surveillance system.

Sources

  1. World Health Organization. Integrated Management of Childhood Illness (IMCI) chart booklet. 2014. General danger signs; very severe febrile disease (danger sign or stiff neck); measles definition and complications; vitamin A; IM ampicillin and gentamicin before referral; malaria rules by risk area.
  2. World Health Organization. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses, second edition. 2013. Emergency signs and shock; differential diagnosis of fever with rash (measles, viral rash, dengue and haemorrhagic fevers); non-blanching petechial or purpuric rash in meningitis and meningococcal septicaemia; maculopapular rash of measles; ceftriaxone in meningococcal epidemics; chemoprophylaxis only for close contacts; glucose threshold.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.