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FEVER AND RASH

Djatnika Setiabudi

Division of Infection – Tropical Disease


Department of Child Health, Faculty of Medicine
Padjadjaran University, Hasan Sadikin General Hospital
Bandung
Introduction
 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

 Knowledge of differential diagnosis is


very important

 Diagnosis
- Accurate anamnesis
- Physical examination
- Supporting examination
Etiologic Agents

Infectious Diseases
 Virus
Classic viral exanthema:
Measles, Rubella, Varicella Zoster
Virus (VZV)
Parvovirus, Roseola (HHV 6 and
HHV 7)
Others: HSV, EBV, HBV, Enterovirus, Dengue

 Bacteria
Scarlet fever, meningococcemia, typhoid fever
Staphylococcal infection (sepsis, toxic shock
Etiologic Agents

 Mycoplasma
 Rickettsia

Noninfectious Diseases
 Allergic: food, drugs, toxin, serum
sickness

 The etiology remains elusive:


Kawasaki disease
Differential Diagnosis

 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
Anamnesis

 Demographic data
 Appearance of rash
 History of exposure
 History of health before
 History of disease in the family
 Other complaint
Physical Examination

 General condition/severity of disease


 Characteristic of rash
 With enanthema
 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

 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,
Diffential Diagnosis of Fever
and Rash
Viruses Bacteria Other

Maculo/papular Measles, rubella, GABHS Rickettsia


HHV-6, Dengue (scarlet fever)
EBV, HBV, HIV, Salmonella, Lyme,
enterovirus Mycoplasma
pneumoniae
Vesicular, bullous VZV, HSV, Echovirus Impetigo (GAS)
Coxsackievirus A, B
(HFMD)

Petechiae Hemorrhagic fever, Sepsis (N.men, Rickettsia


CMV, EBV, VZV S.pneu,Hib)
enterovirus Rat bite fever

Diffuse Dengue GABHS C. albicans


erythroderma (scarlet fever)
TSS
Morbilli (Measles, Rubeola)
Clinical Appearance
 Incubation period: 10–12 days

 Three stadia: prodromal—eruption—


convalescens
 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
Morbilli

 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
Clinical Manifestations of
Morbilli
Rash distribution
from head to lower
extremities

Measl
Koplick’s
spots
es
Conjunctivi
Morbilli

Complications
 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

 Persistent diarrhea
 Exaserbation of TBC
 Keratoconjunctivitis  blindness
 Secondary bacterial infection of skin
 Noma
Rubella (German Measles)

 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
Congenital Rubella
Syndrome
 Depend on gestational age
 Abortus
 Stillbirth
 Congenital anomaly
 Gravida
1–4 weeks: 61%
5–8 weeks: 26%
9–12 weeks: 8%
Congenital Rubella
Syndrome
 Opthalmologic: Cataract -
Micropthalmia
Glaucoma -
Chorioretinitis
 Cardiac: Septal defect - PDA
 Neurologic: Meningoencephalitis
Microcephaly
Mental retardation
 Auditoric: Sensorineural deafness
Exanthema Subitum
(Roseola Infantum)
 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

 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
Prognosis

 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
Scarlet Fever - Scarlatina

Typical rash
Erythroderma diffuse (red sandpaper)
Reddish macule/papule  blanching on
pressure
Firstly
on axilla, groin, and neck  24
hours all of
body
Petechiae can occur
Rash at chin and forehead (confluence):
Scarlet Fever - Scarlatina
 Tongue: white thick membrane
(white strawberry tongue)

 After several days : peeled off 


papule (red strawberry tongue)

 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
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
- 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
Skin rash

 Primary
 Primary rash
rash
Rash:
Rash: morbilliform
morbilliform (maculopapule):
(maculopapule):
chest
chest and joint
joint fold
fold

 Secondary
 Secondary rash
rash
After
After day-4,
day-4, especially
especially day-6
day-6 or
or day-7
day-7
Maculopapule/petechiae
Maculopapule/petechiae /purpura/mixed
/purpura/mixed
Confluence:
Confluence: usually
usually hand
hand and
and foot
Sometimes
Sometimes itching
itching
Dengue Fever (4)

•• Hemorrhage ?

• 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

I II III IV V VI VII VIII

Primary
Primary rash
rash Secondary
Secondary rash
rash
Dengue Virus Infection

Petechia
Flushing
Secondary rash (convalescent rash)
Meningococcemia

 Etiology: Neisseria meningitidis


(meningococcus)

 Clinical manifestations

– Acute fever, suddenly high

– Hemorrhagic manifestations: petechia,


purpura (fulminant)

– Progressive severe 
meningitis, sepsis, septic shock
Meningococcemia
Varicella/Chickenpox
Clinical manifestations
 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
Hand-foot-mouth Disease

 Etiologi
- Coxackie virus type 16 (A 16) >>
- Enterovirus 71 encephalitis
- Others: A5, A7, A9, A10, B2, B5

 Fever, pharyngitis, salivation

 Self-limiting, simptomatic therapy


HFMD HFM
D
Kawasaki disease

 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
Kawasaki Disease

 Diagnosis: fever lasting more than 5


days, plus 4 of the following 5 criteria
(other illnesses with similar clinical
signs must be excluded):
1. Polymorphous rash
2. Bilateral conjunctival injection
3. One or more of the following mucous
membrane changes:
- Diffuse injection of oral and
pharyngeal mucosa
- Erythema or fissuring of the lips
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
Kawasaki
Disease

Polymorpho
us rash
One or more of the following
extremity changes
Indurativ
Erythema e edema
of palms of hands
and/ or and/or
soles feet

Membranous desquamation of the


Bilateral Erythema or
conjunctival fissuring of the
injection lips

Nonpurulent
Strawberry
cervical
tongue
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 benign-
viral 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
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?

 Individual Lesions
Color
Size
Blanches?
Characteristics
THANK YOU
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


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
Differential Diagnosis

 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?
Anamnesis

Demographic Data

 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)
Anamnesis

History of Exposure

 Contac t with similar disease (house,


others)
 Travel
 Pet, insects
 Medicine or other medical measures
 Immunization
Anamnesis

History of health before

 History of disease before


 Growth and development
 History of recurrent disease

History of disease in the family


Autoimmun ?
Anamnesis

Other complaint

 Local complaint (specific organ)

 Systemic complaint
(multiorgan/multisystem diseases)

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