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FEVER and RASH

SYARIFAH HANUM P

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FEVER AND RASH

Definitions

Exanthem: A skin eruption occurring as asymptom of a general disease.

Enanthem: Eruptive lesions on themucous membranes.

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ETIOLOGY

INFECTION

Virus:

Classic viral exanthem: Measles, Rubella, VZV,Parvovirus, Roseola

Others: HSV, EBV, Enterovirus, Dengue

Bacteria: Scarlet fever, Staphylococcal

infection (sepsis, 4S,toxic shocksyndrome), Meningococcemia, Typhoid

Mycoplasma

Rickettsial infection

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NON INFECTIOUS Reactive erythema: erythema multiforme,

urticaria, serum sickness, erythema marginatum

(acute rheumatic fever), erythema chronicummigrans (Lyme disease)

Hypersensitivity syndrome: morbilliform drugeruption, Stevens-Johnson syndrome, toxicepidermal necrolysis, drug reaction w/

eosinophilia and systemic symptoms(DRESS) Vasculitic diseases and purpura: purpura

fulminans, Kawasaki disease, hypersensitivityvasculitis

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CLINICAL PRESENTATION

HISTORY

DURATION: when did it start?

DISTRIBUTION AND PROGRESSION:Where did it begin?

PRODROME:

Where there prodromal symptoms: fever?Cough? Myalgia? Arthralgia? Sore throat?

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ASSOCIATED SYMPTOMS

Pain? Pruritis? Signs of inflammation?

SYSTEMIC MEDICATIONS

Medication administered (up til 1 month before

appearance of rash)?e.g. Phenytoin, carbamazepine, phenobarbital

can cause DRESS

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TOPICAL TREATMENTS AND PRODUCTS

Allergy? Masking effect?

IMMUNOSUPPRESSION

Risks for localized cutaneous infection and

systemic infection

EXPOSURES

To sick persons? Animals? Wildlife?

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TRAVEL

To certain endemic areas? Foreign travel?

PHYSICAL EXAMINATION

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PHYSICAL EXAMINATION

General appearance: well? Toxic?

Examine all areas of the skin, identify primary

lesion and older lesion

Examine mucous membranes

Presence of lymphadenopathy

Musculoskeletal (arthralgia? Arthritis?) Hair and nails

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DIAGNOSTIC TESTS

To help with diagnosis (if necessary)

Needs knowledge about:

- Sample needed- Technique

- Transport/culture media

- Special condition if necessary

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MEASLES/RUBEOLA/CAMPAK

Paramyxovirus

At Risk: Schoolage children who escaped

vaccination

Incubation Period: 718 days

Infectious Period: 1-2 days prior to prodrome

to 4 days after rash onset

Highly Contagious!

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Prodrome: fever, coryza, conjunctivitis, cough

occurs 2-4 days prior to Kopliks spots and 3-5

days prior to exanthem

Enanthem: Kopliks spots appear 2 days prior tothe exanthem and lasts 2 days into the rash

Begins on face around ears as irregular Macules

Lesions spread to trunk in 24-48 hours, become

more papular (purplish-red) and lasts 3-5ds

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Diagnosis

Usually clinical by identifying Kopliks spots or

exanthem

Laboratory identification for public health

purposes

IgM in acute serum most rapid

PCR of throat swab

Viral cultures through Health Department

Serial IgG (acute and convalescent sera)

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Measles: Complications

2007 - 197,000 measles deaths

Otitis Media (7-9%)

Pneumonia (1-6%)severe in children 20 yo

Blindness due to poor nutrition (Vit A def) andmeasles infection

Subacute Sclerosing Panencephalitis (SSPE)

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Measles Treatment

Supportive treatment

Vitamin A in malnourished children

Prevention is key with live attenuated virus

vaccine at 9 mos with second dose at 6 yo

Post-exposure prophylaxis in susceptible

contacts with vaccine within 3 days (preferred)or immune globulin within 6 days followed by

vaccine 5-6 mos later

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SCARLET FEVER/FEBRIS

SCARLATINA

Erthrogenic and pyrogenic exotoxin-

producing Group A beta-hemolyticstreptococci

Usually pharyngeal source, but occasionallycutaneous infection

At risk: < 10 yo, peak 4-8yo

> 10 yo have lifelong antibodies to exotoxins

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Incubation Period: 24 days

Infectious Period: during acute infection,

gradually diminishes over 3 weeks

reduced by good handwashing

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clinical features

Abrupt onset fever, headache,

vomiting,malaise, sore throat

Enanthem

Bright red oral mucosa

Palatal petechiae

Strawberry tongue (initially white coatingappears and then on 4-5th day,

reddened,edematous papillae prominent)

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Exanthem

12-48 hours after fever onset

Diffuse punctate erythematous eruption with

sandpaper texture

Lasts 2-3 weeks

Pastias lines distinguishing feature,increases

capillary fragility leads to transverse

hyperpigmentation with petechiae in antecubital

fossa, axillary folds, inguinal folds

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Pastias lines

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Scarlet Fever Desquamation

Desquamation of palms, soles, knees,

elbows

10 ds later, can last up to one month

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Scarlet fever
http://www.dermnet.com/image.cfm?passedArrayIndex=11&moduleID=24&moduleGroupID=328

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Scarlet fever: Complications

Suppurative Complications

Otitis media Sinusitis

Peritonsillar/Retropharyngeal Abscesses

Cervical Adenitis

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Scarlet fever

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Scarlet fever

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RUBELLA/GERMAN

MEASLES/CAMPAK JERMAN

Togavirus

At risk: Unvaccinated adolescents

Incubation Period: 14-21

days

Infectious Period: 5-7 days prior to rash to 3-

5days after rash onset

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Clinical Features

Asymptomatic infection in up to 50%

Prodrome

-Children: absent to mild

-Adolescents and Adult: Fever, malaise,

sore throat, nausea, anorexia, painful

occipital LAD Enanthem

-Forschheimers spots petechiae on hard

palate

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Exanthem:

- Starts on face and fades from face in 24 hours

- Notable featureappearance rapidly changesin few hours

- Pink-red lesions seen as opposed to purplishred lesions seen with measles

Diagnostic testingIgM in acute serum orserial IgG in acute and convalescent sera

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Complications

Generally benign disease

Arthralgias/arthritis in older patients

Peripheral neuritis, encephalitis, TTPrare Congenital Rubella Syndrome: 30-50% risk if

infected in the first 6 weeks of 1st trimester of

pregnancy; IUGR, cataracts, microcephaly,

deafness,cardiac defects, anemia,

thrombocytopenia

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4th Disease = Filatow-Dukes

Disease

1900

Controversial and initially diagnosed

basedupon clinical and morphologicalexamination

No lab facilities to allow proper classification

1979epidermolytic exotoxin-producingStaph aureus causing erythematous cellulitisthen exfoliative dermatitis

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ERYTHEMA INFECTIOSUM (5th-

DISEASE)

Human Parvovirus B19

At risk: School-age children

Season: Sporadic Incubation Period: 4-14 days

Infectious Period: Up until the onset of the

exanthem, only contagious in the first stage

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Clinical Features

Over 50% of infections are asymptomatic

Prodrome: Mild fever (15-30%), sore throat,malaise

Adultsflu-like symptoms,

arthralgias/arthritis (potentially chronic, more

common in women)

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1st Stage

Day #1

Slapped Cheek

Contagious only during this stage

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2nd Stage

Day #2

Erythematous maculopapular eruption

Extensor surfaces

of extremities

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3rd Stage

Day #6

Reticular pattern (pathognomonic)

Central clearing

Lasts 9-11 days

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Complications

Result of viral infection of erythrocyte precursorcells

Monitor patients at risk for transient aplastic

crisis pRBC Transfusion as indicated

Hydrops fetalis (severe anemia causes highoutput cardiac failure with fetal death rate of 1-

5%) Raynauds Phenomenon immune-mediated

endothelial damage causes vasoconstriction

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Papular Purpuric Glove and Sock

Syndrome

2nd syndrome ascribed to Parvovirus B19

Young Adults Exanthem, LAD, fever, anorexia, arthralgias

Self-limited over 7-14 days

Viremia clears after rash

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EXANTHEMA SUBITUM/ROSEOLA

INFANTUM

Human Herpes Virus 6 and 7

At risk: 6-36 mos (peak age 6-7 mo) Season: Sporadic

Incubation period: 9 days

Infectious Period: Virus is intermittently shedinto saliva throughout life; asymptomatic

persistent infection

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Clinical Features

High fever for 3-4 days

Otherwise well

appearing child Abrupt defervescence with appearance of

rash

Febrile Seizures (6-15%)due to rapid rate

of fever progression or localized infection of

meninges or host factors?

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Exanthem

- Erythematous maculopapules 2-3mm

- Rarely coalesce- Initially present on trunk

- Blanches

- Benign disease usually withoutcomplications/sequellae

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The rest of the herpes family

Herpes simplex virus 1 and 2

Varicella-zoster virus Cytomegalovirus

Epstein-Barr virus

Human Herpes virus 6 and 7 Human Herpes virus 8

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Enterovirus rashes

Hand-foot-mouth disease Herpangina

Nonspecific eruptions

HAND FOOT AND MOUTH

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HAND FOOT AND MOUTH

DISEASE

Typically due to Coxsack ie A16

At risk: preschool-school aged children Highly contagious

Incubation period: 4-6 days

Prodrome: 1-2 days before rash Low-grade fever, anorexia, malaise, sore

mouth

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HERPANGINA

Coxsackie A viruses

At risk: young children

Prodrome: Fever, sore throat

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DENGUE FEVER AND DENGUE

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DENGUE FEVER AND DENGUE

HEMORRHAGIC FEVER

DENGUE FEVER

50-82% of patients

Initial rash: transient erythema of the face

24-48 hrs after onset of fever

Second rash: maculopapular or morbiliformeruptiom

4-6 days after onset of feverConvalescence rash: purpuric eruption on hands,

forearms, feet, legs

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DENGUE HEMORRHAGIC FEVER

Similar with DF

Sometime with hemorrhagic manifestation:

purpura, ptechiae, ecchymoses

DHF

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DHF

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Seorang anak perempuan berusia 2 tahun dibawaibunya ke RS YARSI karena demam denganbintik-bintik merah. Sejak 2 hari yang lalu anaktersebut demam tidak tinggi dan sehari sebelum

ke rumahsakit keluar bintik-bintik merah mulaidari muka yang kemudian menyebar ke seluruhtubuh. Tidak didapatkan keluhan yang lain. Anakbelum pernah immunisasi sejak lahir. Padapemeriksaan fisik didapatkan frekuensi nadi100x/menit, frekuensi napas 28x/menit, suhutubuh 37,80C, terdapat ruam makulopapulartersebar di seluruh tubuh dan pembesarankelenjar limfe oksipital multipel.

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Seorang anak laki-laki berusia 6 tahun dibawa ke puskesmaskarena mimisan. Mimisan sudah berhenti ketika sampai dipuskesmas. Anak tersebut juga menderita demam yangsudah berlangsung 3 hari, demam tinggi sepanjang haridengan nyeri kepala. Tidak ada batuk maupun pilek, buang

air kecil dan buang air besar normal. Pemeriksaan fisik:anak sadar penuh, tekanan darah 100/70 mmHg, frekuensinadi 120x/menit, frekuensi napas 36x/menit, suhu 39,50C.Hepar teraba 2 cm di bawah arkus kostarum, tepi tajam,permukaan licin, konsistensi kenyal, akral hangat, perfusi

jaringan baik. Lain-lain dalam batas normal. Hasilpemeriksaan laboratorium sbb: jumlah leukosit 2300/L,hematokrit 38 vol%, jumlah trombosit 125.000/L

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