Transcript Fever and rash (English) Revisi

FEVER AND RASH
Prof. H. Herry Garna, dr., Sp.A(K), Ph.D
Infection – Tropical Disease Subdivision
Department of Child Health, Faculty of Medicine
Padjadjaran University, Hasan Sadikin General Hospital
Bandung
Introduction
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Fever is often the first symptom noted by parents,
common problem in clinic
Wide range of severity:
 self limiting disease  life-threatening
Wrong first suspicion  fatal outcome
It is more likely to be caused by infection, but any
inflammatory, neoplastic, immunologic or traumatic
event can generate fever
Introduction
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Knowledge of differential diagnosis is very
important
Diagnosis
- Accurate anamnesis
- Physical examination
- Supporting examination
Differential Diagnosis
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Past history of infectious disease and
immunization
Type of prodromal period
Feature of the rash
Presence of pathognomonic or other diagnostic
signs
Laboratory diagnostic tests
Differential Diagnosis
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Feature of the rash
* Category:
- Macular or maculo-papular:
Morbilli, rubella, roseola infantum,
scarlatina
- Papulo-vesicular:
Varicella, herpes zoster, variola
* Character: discrete or confluent
* Distribution, duration
* The appearance associated with fever?
Etiologic Agents
Infectious Diseases
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Virus
Classic viral exanthema:
Measles, Rubella, Varicella Zoster Virus (VZV)
Parvovirus, Roseola (HHV 6 and HHV 7)
Others: HSV, EBV, HBV, Enterovirus, Dengue
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Bacteria
Scarlet fever, meningococcemia, typhoid fever
Staphylococcal infection (sepsis, toxic shock syndrome)
Etiologic Agents
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Mycoplasma
Rickettsia
Noninfectious Diseases
 Allergic: food, drugs, toxin, serum sickness
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The etiology remains elusive: Kawasaki disease
Anamnesis
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Demographic data
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Appearance of rash
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History of exposure
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History of health before
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History of disease in the family
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Other complaint
Anamnesis
Demographic Data
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Age: neonate, infant, older children
Sex
Ethnic/race : Kawasaki disease ?
Season: winter or dry season or not specific
Certain geographic: endemic
Anamnesis
Appearance of rash
Location and distribution
 Expansion and evolution
 Correlation between rash and fever
 in the period of high fever (morbilli)
 in the period of decreasing fever (roseola infantum)
 Pain or itching (drug eruption: itching)
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Anamnesis
History of Exposure
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Contac t with similar disease (house, others)
Travel
Pet, insects
Medicine or other medical measures
Immunization
Anamnesis
History of health before
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History of disease before
Growth and development
History of recurrent disease
History of disease in the family
Autoimmun ?
Anamnesis
Other complaint
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Local complaint (specific organ)
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Systemic complaint (multiorgan/multisystem
diseases)
Physical Examination
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General condition/severity of disease
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Characteristic of rash
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With enanthema
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Other physical disorders
Physical Examination
General condition/severity of disease
 Meningococcemia, Staphylococcal toxic syndrome
Characteristic of rash
Macule, papule, maculo-papule
 Vesicle, pustule, bulla
 Petechiae or purpura
 Erythroderma: diffuse or local
Nonblanching lesions
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Petechiae, purpura, and echymosis
Difference size
Petechiae diameter <2 mm
Purpura 2 mm–1 cm
Echymosis diameter >1 cm
Physical Examination
With enanthema
 Mouth: Hand-foot-mouth disease?
Buccal mucosa, palatum, pharyng, and tonsil
 Genital mucosa
Others
 Arthritis, eye disorders, cardiac disorders
 Hepatomegaly, splenomegaly, lymphadenopathy
Diffential Diagnosis of Fever and Rash
Viruses
Bacteria
Other
Maculo/papular
Measles, rubella,
HHV-6, Dengue
EBV, HBV, HIV,
enterovirus
GABHS
(scarlet fever)
Salmonella, Lyme,
Mycoplasma
pneumoniae
Rickettsia
Vesicular, bullous
VZV, HSV, Echovirus
Coxsackievirus A, B
(HFMD)
Impetigo (GAS)
Petechiae
Hemorrhagic fever, Sepsis (N.men,
CMV, EBV, VZV
S.pneu,Hib)
enterovirus
Rat bite fever
Rickettsia
Diffuse
erythroderma
Dengue
C. albicans
GABHS
(scarlet fever)
TSS
Morbilli (Measles, Rubeola)
Clinical Appearance
 Incubation period: 10–12 days
 Three stadia: prodromal—eruption— convalescents
 Prodromal: 3–5 days
3 C (Coryza, Conjunctivitis, Cough), fever, Koplick’s spots
 Eruption: high fever (40–40,5°C)  Typical rash:
- Maculo-papular erythromatous
- Confluence-general
- Start from backside of ear (head)  body and upper arm 
lower extremities during 3 days  whole of body
Morbilli
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Endemic in developing countries
Effective immunization program
 cases decreasing
 prone to older age group
Lesion particularly at skin, mucous membrane,
conjunctiva
Serous exudate, mononuclear cell predominant
Diagnosis
Anamnesis
* Symptoms
* History: contact, immunization
 Clinical signs
* Typical
 Laboratory examination
* Leukopenia
* Relative lymphocytosis
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Clinical Manifestations of Morbilli
Rash distribution from head
to lower extremities
Measles
Koplick’s spots
Conjunctivitis
Morbilli
Complications
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Acute otitis media (10–15%)
Pneumonia interstitialis (50–75% with radiologic
abnormalities)
Myocarditis and pericarditis
Encephalitis (1/1,000 cases) 7–10 days after rash appearance
(1/3 dead, 1/3 physical defect, 1/3 recover )
Subacute sclerosing panencephalitis (SSPE)
(0,2–2 /100,000 morbilli, mean incubation 7 years)
CFR almost 100% after 6–9 months
Complications
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Persistent diarrhea
Exaserbation of tuberculosis (TBC)
Keratoconjunctivitis  blindness
Secondary bacterial infection of skin
Noma
Rubella (German Measles)
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Prodromal sign: +/Rash: short period  3 days
Typical sign: lymphadenopathy postauricular,
suboccipital, posterior colli
Problems in pregnant women  congenital
rubella syndrome
Clinical Manifestations
Incubation period: 15—21 days
 Mild prodromal sign:
- mild fever
- adolescent: more severe
 Rash: maculopapular
face  centrifugal to neck  trunk, extremities 
24 hours all of body  resolve in 3rd day
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Congenital Rubella Syndrome
Depend on gestational age
 Abortus
 Stillbirth
 Congenital anomaly
 Gravida
1–4 weeks: 61%
5–8 weeks: 26%
9–12 weeks: 8%
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Congenital Rubella Syndrome
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Opthalmologic: Cataract - Micropthalmia
Glaucoma - Chorioretinitis
Cardiac: Septal defect - PDA
Neurologic: Meningoencephalitis
Microcephaly
Mental retardation
Auditoric: Sensorineural deafness
Exanthema Subitum (Roseola
Infantum)
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Acute infection caused by human herpes virus 6
(some HHV 7)
Mostly in infant
Sporadic (sometimes epidemic)
Typical feature:
- Severity of clinical sign unproportionally
with degree of fever
- Simultaniously resolve of rash and clinical sign
Clinical Manifestation
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Incubation period: 7–17 days (mean 10 days)
Most common in 6–18 months old
Fever
- abruptly high: 39,4–41,2°C
- duration: 1–5 days (mostly 3–4 days)
- convulsion can occur
Mild clinical sign: mild pharyngitis and coryza
Rash: not specific: macule/maculopapular, rose color 
chest  extremities and neck  face
Appear while temperature has return to normal
Disappear on 1–2 days with normal skin
Prognosis
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Particularly good prognosis
Bad prognosis:
Hyperpyrexia with persistent convulsion
Scarlet Fever - Scarlatina
Clinical manifestation
 Incubation period: 1–7 days (mean: 3 days)
 Acute symptoms: high fever—headache—
vomiting—chills
 Signs: severe pharyngitis  hyperemia—
edema— exudate—dysphagia
 Sometimes abdominal pain
 Enlargement of lymph node
Scarlet Fever - Scarlatina
Typical rash
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Erythroderma diffuse (red sandpaper)
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Reddish macule/papule  blanching on pressure
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Firstly on axilla, groin, and neck  24 hours all of
body
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Petechiae can occur
Rash at chin and forehead (confluence): circumoral
palor
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Usually: palms and soles of feet
Scarlet Fever - Scarlatina
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Tongue: white thick membrane
(white strawberry tongue)
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After several days : peeled off 
papule (red strawberry tongue)
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Pintpoint petechiae in the flexures
produce a linear purpuric pattern
(pathognomonic)(Pastia’s lines)
Scarlet Fever (Scarlatina)
A beta-hemolytic Streptococcus group 
pyrogenic toxin (erythrogenic toxin)
Desquamation occur from end of 1st week to 6th week of
disease
Diagnosis: History and physical examination
Pharyngeal swab: bacterial culture
Serologic: ASTO/ASLO/ASO
Complete blood count: leukocytosis
CRP increased or +: not specific
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Scarlet Fever - Scarlatina
Desquamation of rash after 1 week,
especially in hand and foot
Complications
Local spread/per continuitatum:
- Sinusitis – otitis media – mastoiditis
- Retro/parapharyngeal abcess
- Brochopneumonia
- Servical adenitis
 Hematogenic spread
 - Meningitis – osteomyelitis – arthritis (septic)
 Non suppurative (late) complications
- Acute rheumatic fever
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- Acute glomerulonephritis
Dengue Fever (1)
• Incubation period: 3–14 days
• Fever: suddenly high
 disappear: day-3 or 4  recover or
 dicrease: day-3 atau 4 , and appear again
after 1–3 days  camel saddle
 Long of fever: 5–7 days
Dengue Fever (2)
Other complaint
• Headache, retro orbital pain
• Joint pain, back pain (backborne fever)
• Weakness, malaise
• Flushing: face, neck
• Photophobia, cough
Dengue Fever (3)
Skin rash
 Primary rash
Rash: morbilliform (maculopapule):
chest and joint fold
 Secondary rash
After day-4, especially day-6 or day-7
Maculopapule/petechiae /purpura/mixed
Confluence: usually hand and foot
Sometimes itching
Dengue Fever (4)
• Hemorrhage
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• Although not usual  hemorrhage
- petechiae (skin)
- epistaxis
- gum bleeding, vomiting/with blood
- menorrhage
Pattern of Fever in Dengue Infection
40 oC
39 oC
38 oC
37 oC
36 oC
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II
Primary rash
III
IV
V
VI
VII VIII
Secondary rash
Dengue Virus Infection
Flushing
Secondary rash (convalescent rash)
Meningococcemia
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Etiology: Neisseria meningitidis (meningococcus)
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Clinical manifestations
– Acute fever, suddenly high
– Hemorrhagic manifestations: petechia, purpura (fulminant)
– Progressive severe  meningitis, sepsis, septic shock
Meningococcemia
Varicella/Chickenpox
Clinical manifestations
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Prodromal: 1–2 days, mild fever
Papular erythromatous
 vesicle  pustule  crusta
Distribution of rash from body to face
 neck and extremities
Pruritus +++
Mucous membrane
Spesific: several kinds of rash in
the same time
Varicella/Chickenpox
Complication
 Pneumonia
(rare in children, high mortality in
immunocompromised hosts
 Cerebellar ataxia (1/4.000: age <15 yr)
(Develops 7 to 10 days into the disease,
excellent prognosis)
 Transvere myelitis, Guillain-Barre
syndrome
 Hemorrhagic: thrombocytopenia
Varicella/Chickenpox
Complication
 Superinfection
- local: S. aureus or GABHS: cellulitis
- systemic: GABHS: sepsis, necrotizing fasciitis,
streptococcal toxic shock syndrome
 Reye Syndrome
Persistent vomiting, decreased mental status, liver
dysfunction
Associated with salicylate-containing products
Avoid aspirin in varicella !!!
Hand-foot-mouth Disease
Etiologi
- Coxackie virus type 16 (A 16) >>
- Enterovirus 71 encephalitis
- Others: A5, A7, A9, A10, B2, B5
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Fever, pharyngitis, salivation
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Self-limiting, simptomatic therapy
HFMD HFMD
Kawasaki disease
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First described in 1967
Incidence: 67 cases /100,000 in Japan
5.6 cases/100,000 in USA
85% in children < 5 years (peak 18–24 mo)
Rarely occurs in adolescent, adults or children < 6 mo
M/F ratio 1.4:1
Occurs often in late winter and spring
Etiology: Unknown
Pathophysiology: « Superantigen theory » causing an
intense vasculitis
Kawasaki Disease
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Diagnosis: fever lasting more than 5 days, plus 4 of
the following 5 criteria (other illnesses with similar
clinical signs must be excluded):
Polymorphous rash
Bilateral conjunctival injection
One or more of the following mucous membrane
changes:
- Diffuse injection of oral and pharyngeal mucosa
- Erythema or fissuring of the lips
- Strawberry tongue
Kawasaki Disease
4.
Acute, nonpurulent cervical lymphadenopathy
(one lymph node must be >1.5 cm)
5. One or more of the following extremity changes:
- Erythema of palms and/or soles
- Indurative edema of hands and/or feet
- Membranous desquamation of the fingertips
Kawasaki Disease
Polymorphous
rash
One or more of the following extremity
changes
Indurative
edema of
hands
and/or feet
Erythema of
palms and/
or soles
Membranous desquamation of the fingertips
Bilateral conjunctival
injection
Strawberry tongue
Erythema or fissuring
of the lips
Nonpurulent cervical
lymphadenopathy
Conclusions
Children Who Present Fever and Rash
Group 1 : children with symptoms of serious illness who require
immediate intervention
Group 2 : children with a clearly recognizable-and usually benignviral syndrome
Group 3 : children who present early in the course of the disease,
when the clinical picture and physical findings are
nonspecific, and those with undifferentiated rashes with
fever
Key Questions
Acute or Chronic (Recurrent)?
When did it start?
Pattern of Spread?
Sick or Well?
Pruritic?
Medications?
Exposures?
Describe What You See
Pattern/Distribution
Diffuse or Localized?
Mucous Membranes?
Palms & Soles?
Exposed vs. Unexposed Areas?
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Individual Lesions
Color
Size
Blanches?
Characteristics
Other Physical Findings
Common Primary Skin Lesions
Macule : Circumscribed area of change in normal skin color,
with no skin elevation or depression; may be any size
Papule : Solid, raised lesion up to 0.5 cm in greatest diameter
Nodule : Similar to papule but located deeper in the dermis or
subcutaneous tissue; differentiated from papule by
palpability and depth, rather than size
Plaque : Elevation of skin occupying a relatively large area in
relation to height; often formed by confluence of
papules
Common Primary Skin Lesions
Vesicle : Circumscribed, elevated, fluid-containing lesion less
than 0.5 cm in greatest diameter; may be
intraepidermal or subepidermal in origin
Bulla
: Same as vesicle, except lesion is more than 0.5 cm
in diameter
Pustule : Circumscribed elevation of skin containing purulent
fluid of variable character (i.e., fluid may be white,
yellow, greenish or hemorrhagic)