What is the best course of action for an 8-year-old female patient presenting with stomatodynia (burning sensation in the mouth) and fever?

Immediate Evaluation for Serious Bacterial Infection

This 8-year-old with burning mouth sensation and fever requires urgent assessment to exclude serious bacterial infections, particularly Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), meningitis, and other life-threatening conditions before considering benign causes like primary burning mouth syndrome.

Critical Red Flags Requiring Immediate Action

Examine the oral mucosa thoroughly for mucosal lesions, blistering, or erythema that could indicate SJS/TEN, which presents with oral involvement in nearly all cases and requires immediate hospitalization 1. Look specifically for:

• Detached or sloughing oral mucosa
• Hemorrhagic crusting of lips
• Painful erosions or ulcerations
• Conjunctival involvement or skin lesions elsewhere 1

If any mucosal lesions or systemic signs are present, this is a medical emergency requiring immediate hospitalization and specialist consultation 1.

Fever Evaluation in This Age Group

For an 8-year-old with fever, assess for:

• Signs of meningism (neck stiffness, photophobia, altered consciousness) - if present, lumbar puncture is mandatory 1
• Respiratory symptoms or work of breathing - consider chest radiograph if clinically indicated 1
• Urinary symptoms - urinalysis should be obtained if no other source identified 1
• Duration and pattern of fever - fever lasting >3 days warrants medical reevaluation 2

Administer acetaminophen for fever control and comfort (age-appropriate dosing per FDA labeling), but this does not replace the need for diagnostic evaluation 2.

Differential Diagnosis for Burning Mouth with Fever

Infectious Causes (Priority in Febrile Child)

Oral candidiasis must be excluded by visual inspection and, if white plaques present, scraping with KOH preparation 3, 4. This is particularly important as it can cause burning sensation and is treatable.

Scarlet fever and Kawasaki disease can present with oral burning, fever, and characteristic tongue findings (strawberry tongue) and must be excluded 3. Look for:

• Sandpaper-like rash (scarlet fever)
• Conjunctival injection, cervical lymphadenopathy, extremity changes (Kawasaki disease)

Herpes simplex virus can cause severe oral pain and fever in children and requires specific antiviral therapy 1.

Secondary Causes of Burning Mouth (Less Likely with Acute Fever)

If fever resolves but burning persists, obtain:

• Complete blood count with differential to identify anemia 3, 4
• Vitamin B12 level - deficiency causes secondary burning mouth syndrome 3, 4
• Iron studies (ferritin, serum iron, TIBC) - iron deficiency frequently presents with burning tongue 3, 4
• Thyroid function tests - hyperthyroidism can cause tongue erythema and burning 3, 4

Management Algorithm

Immediate (Day 1)

1. Complete physical examination including thorough oral cavity inspection, skin examination, and assessment for meningeal signs 1
2. If mucosal lesions present: Immediate hospitalization, dermatology and ophthalmology consultation, consider SJS/TEN 1
3. If signs of meningism: Lumbar puncture after ensuring no contraindications 1
4. If well-appearing with isolated oral symptoms: Obtain CBC, consider throat culture, assess for candidiasis 3, 4

If Fever Persists Beyond 3 Days

Return for reevaluation as this could indicate serious underlying condition 2. Consider:

• Blood cultures if systemically unwell
• Chest radiograph if respiratory symptoms develop
• Urinalysis and culture

If Burning Persists After Fever Resolves

Complete laboratory workup including CBC, B12, iron studies, and thyroid function 3, 4.

Primary burning mouth syndrome is extremely rare in children and should only be diagnosed after excluding all secondary causes 3, 5. In the rare pediatric case, cognitive behavioral therapy is the primary intervention, with gabapentin as first-line pharmacological treatment if needed 6, 4.

Critical Pitfalls to Avoid

• Never dismiss oral burning with fever as benign BMS - this combination in a child warrants thorough infectious disease workup 1, 3
• Do not delay evaluation for SJS/TEN - early recognition and supportive care significantly impacts morbidity and mortality 1
• Ensure close follow-up - instruct parents to return immediately if new symptoms develop, including rash, worsening oral pain, difficulty swallowing, or altered consciousness 1

If symptoms worsen, new symptoms occur, or fever persists beyond 3 days, immediate medical reevaluation is mandatory 2.