Question: If children demonstrate acrocyanosis around the time of developing a fever, is the cause of fever more likely to be bacterial?

Near the time of developing a fever, we have anecdotally observed that children will sometimes demonstrate acrocyanosis. Does this acrocyanosis serve as a prognostic indicator of an underlying bacterial illness? To better address this question, we begin with a prospective observational cohort study of 239 children that evaluated the diagnostic ability of clinical recognition signs (CRS) to identify sepsis.¹ The authors evaluated four parameters for their ability to predict severe illness in the pediatric ED setting: altered mental status, abnormal capillary refill, abnormal peripheral pulses, and cold or mottled extremities. In regard to abnormally prolonged capillary refill, the positive likelihood ratio for identifying organ dysfunction within 24 hours was average, at 0.5. The authors mention that “CRS were not associated with intravenous antibiotics administration, SBI [serious bacterial illness], or admission.” This study did not suggest that abnormal capillary refill (a scenario similar to acrocyanosis) predicts SBI. A separate 2017 prospective observational study by de Vos-Kerkhof, et al., evaluated both peripheral (pCRT) and central (cCRT) capillary refill time and its utility in identifying children with serious bacterial infection.² The study included 1,193 consecutive children aged 1 month to 16 years, and SBI was defined as pneumonia, meningitis, and UTI. Children had their capillary refill checked at arrival to the pediatric ED and it was classified as normal (less than or equal to 2 sec), prolonged (greater than 2 sec—less than or equal to 4 sec), or severely prolonged (greater than 4 sec). The authors state that “both pCRT and cCRT had no diagnostic value for the detection 0f SBI.” For the pCRT, the OR for an SBI was 1.10 (95 percent CI, 0.65–1.84), suggesting that the development of delayed capillary refill is not associated with an SBI.

Summary

While the data is overall rather limited on this topic, the development of delayed capillary refill does not appear to predict the likelihood of an SBI.

Dr. Jones is assistant professor of pediatric emergency medicine at the University of Kentucky in Lexington.

Dr. Cantor is professor of emergency medicine and pediatrics, director of the pediatric emergency department, and medical director of the Central New York Regional Poison Control Center at Upstate Medical University in Syracuse, New York.

References

1. Scott HF, et al. Effectiveness of physical exam signs on early detection of critical illness in pediatric systemic inflammatory response syndrome. BMC Emerg Med. 2014;14:24.
2. De Vos-Kerkhof E, et al. Comparison of peripheral and central capillary refill time in febrile children presenting to a paediatric emergency department and its utility in identifying children with serious bacterial infection. Arch Dis Child. 2017;102(1):17-21.