27-Oct-18

INFORMASI UMUM
• Presentasi ini disampaikan pada kegiatan 1ST ASMP-ID
• Hari / Tanggal : Sabtu - Minggu / 27-28 Oktober 2018
• Tempat : Hotel Novotel Tangerang
• Narasumber : UKK Infeksi dan Penyakit Tropis

• Semua isi dan materi presentasi adalah hak cipta dari

narasumber, digunakan untuk kalangan terbatas dalam
kepentingan edukasi kesehatan di bidang terkait.

Infectious and Tropical Disease Working Group of Indonesian Pediatric Society

In collaboration with 1
Indonesian Pediatric Society (IPS) – Banten Branch

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Infectious and Tropical Disease Working Group of Indonesian Pediatric Society

In collaboration with 2
Indonesian Pediatric Society (IPS) – Banten Branch

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Curiculum Vitae
• Nama : Yulia Iriani
• Institusi : Divisi Infeksi dan Penyakit Tropis
Departemen Kesehatan Anak FK UNSRI/
RS Mohammad Hoesin Palembang
• Pendidikan : S1 FK UNPAD (1995)
SpA FKUI (2004)
S3 FK UNAIR (2011)
Fellowship IPT FK UNPAD (2013)

Infectious and Tropical Disease Working Group of Indonesian Pediatric Society

In collaboration with
Indonesian Pediatric Society (IPS) – Banten Branch

Non–Blanching Rash
Kewaspadaan terhadap Infeksi Meningococcus
Yulia Iriani

Infectious and Tropical Disease Working Group of Indonesian Pediatric Society .

In collaboration with .
Infectious and Tropical Disease Working Group of Indonesian Indonesian Pediatric
Pediatric Society Society (IPS) – Banten Branch .
In collaboration with
Indonesian Pediatric Society (IPS) – Banten Branch

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Introduction
• Non-blanching rash (NBR)
• Concern by doctors and parents
• Infectious diseases with haemorrhagic rash can be fulminant fatal events or
relatively benign illnesses
• 90% will NOT have MCD
• is one of the most recognised signs of possible meningococcal disease (MCD)
• 20% MCD do not have NBR
• Wide range of underlying diagnosis
• some of which are life threatening  MCD

Non-blanching rash (NBR) - Definition

• Non-blanching rash (NBR) is a term for any rash in which the colour is
unchanged with direct pressure.
• Petechiae or purpura

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NBR – Etiology
• Infection • Mechanical
• Viral • coughing or vomiting local pressure or
• Common: Enterovirus and tourniquet application, strangulation
adenovirus • Hematological
• Bacterial
• Thrombocytopenia, leukemia and
• Meningococcal disease (MD) hypersplenism, platelet dysfunction,
• Haemophillus influenzae B coagulopathy
• Infeksi Streptococcal • Vascular
• Infective endocarditis
• Vasculitis, scurvy, drugs, fat embolism,
• Ricketsia dysproteinemia

Tabel. Infectious Agents Associated with Illnesses in Which Petechial and Purpuric Exanthems
Occur
Infectious Agents
Human parvovirus B19
Varicella zoster virus
Cytomegalovirus
Variola virus
Coxsackieviruses A4, A9
Coxsackieviruses B2–B4
Echoviruses 4, 7, 9
Colorado tick fever virus r
Rotavirus
Alphaviruses: chikungunya,
o’nyong- nyong fever, Ross
River, Sindbis
Rubella virus
Respiratory syncytial virus
Measles virus
Lassa virus
Marburg virus
Hepatitis C virus
Hantavirus
Infectious Agents
Disease Rickettsia typhi
Gloves-and-socks syndrome Rickettsia prowazekii
Hemorrhagic chickenpox Rickettsia rickettsii and other
Congenital cytomegalovirus infection
Ehrlichia spp.
Hemorrhagic smallpox
Mycoplasma pneumoniae
Streptococcus pyogenes
Streptococcus pneumoniae
Enterococcal and viridans group
Colorado tick fever
Neisseria gonorrhoeae
Neisseria meningitidis
Moraxella catarrhalis
Haemophilus influenzae
Rubella atau congenital rubella Pseudomonas aeruginosa
Streptobacillus moniliformis
Hemorrhagic (black measles) atau atypical measles Yersinia pestis
Lassa fever Bartonella henselae
Treponema pallidum
Mixed cryoglobulinemia Borrelia spp.
Hemorrhagic fever with renal syndrome Toxoplasma gondii
Disease
Murine typhus
Epidemic typhus
Rocky Mountain spotted fever tick-borne rickettsiae
Ehrlichiosis
Scarlet fever atau septicemia
Pneumococcal septicemia
Endocarditis streptococci
Gonococcemia
Meningococcemia
H. influenzae septicemia
Ecthyma gangrenosa
Septicemic plague (black death)
Cat-scratch fever
Congenital syphilis
Relapsing fever
Congenital toxoplasmosis

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Anatomic Spread of Clinical

location agent Histology expressions Pathophysiology
NBR–Pathogenesis Blood Free in Associated
plasma with
leukocytes

Rash mechanisms: Dermal Infection Damage to vessel, Macule, Direct effect of

capillary endothelial papule, agent or immune
endothelium swelling, petechia reaction with
• mechanical capillary injury perivascular pathologic
edema, cellular consequences
infiltration,
• impaired haemostasis hemorrhage

• septic emboli or invasion To dermis To dermis by

through diapedesis
of the capillary wall breaks in
basement
membrane
• microbial toxin-induced (secondary Contiguous
capillary damage to trauma) spread

Dermis Infection Edema, cellular Papule, Direct effect of

• immune complex infiltration, urticaria, agent or immune
hemorrhage, purpura, reaction with
deposition microscopic vesicle pathologic
Contiguous
visualization of consequences;
spread
organism histamine release

Epidermis Infection Cytopathic effects Papule, Direct effect of

(inclusions, vesicle, agent
ballooning, ulcer
vacuolation,
necrosis, nuclear
Gambar 1. Aspects of pathogenesis in exanthems associated disruption),
microscopic
with blood-borne dissemination of the infectious agent visualization of
(Modified from Cherry JD. Newer viral exanthems. Adv Pediatr. 1969;16:233–86.) organism

Assessing NBR
• Is the child well?
• Can I make a positive diagnosis?
• Can I rule out serious illness?

Children with purpura who are ill-appearing or febrile

require rapid evaluation and treatment for serious hemorrhage, DIC, or infection.

Fever – Serious infection is an important cause of purpura in children

and is usually associated with fever

General examination – The overall appearance of a child will help guide further management.
Patients who have purpuric lesions and are ill-appearing and/or hemodynamically unstable need to
be rapidly assessed to determine the underlying etiology

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• MCD indicators (or other serious

bacterial infection):
• Unwell child
• Purpura > 2mm (unless clinical
picture is suggestive for HSP)
• Abnormal blood indices (WBC >
15x109/L or <5x109/L and CRP> 8
mg/L)

http://pediatrics.aappublications.org/content/72/4/469

Table. Age-specific frequency of clinical features of MCD

prior to hospital admission.

Table. Age-specific frequency of clinical features of MCD

prior to hospital admission.

Ninis N, Nadel S, Glennie L (2010) Lessons from Research for Doctors in Training:
Recognition and Early Management of Meningococcal Disease in Children and
Young People.

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Take Home Messages

• There are many cause of non-blanching rash (NBR)
• Assess all patients with suspected purpura for features of serious illness
• One of the characteristic signs of meningococcal disease is a NBR, although this
may be absent in up to 20% of cases
• Clinical signs and laboratory investigations will help determine those who should
be treated for suspected meningococcal disease

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TERIMA KASIH