Case 7:Case 7:“Pesteng Lamok”“Pesteng Lamok”

““PESTENG LAMOK”PESTENG LAMOK”

A 7 year old male child has been having A 7 year old male child has been having fever (maximum 39fever (maximum 3900C) for the past 4 C) for the past 4 days.This was associated with generalized days.This was associated with generalized body malaise, chilliness, headache and body malaise, chilliness, headache and muscle pains. A few hours before muscle pains. A few hours before admission, he complained of severe admission, he complained of severe abdominal pain. Two other classmates abdominal pain. Two other classmates were hospitalized earlier for the same were hospitalized earlier for the same complaints. complaints.

““PESTENG LAMOK”PESTENG LAMOK”

PE showed a febrile child with RR PE showed a febrile child with RR 26/min.; HR 110/min.; congested posterior 26/min.; HR 110/min.; congested posterior pharyngeal walls with several petechiae pharyngeal walls with several petechiae on the hard palate, few petechiae on the on the hard palate, few petechiae on the axilla and chest. Chest and abdominal axilla and chest. Chest and abdominal findings were essentially normal. He was findings were essentially normal. He was given IVF and CBC and platelet counts given IVF and CBC and platelet counts were requestedwere requested

Guide QuestionsGuide Questions

1.1. What conditions will manifest with fever What conditions will manifest with fever and petechiae/purpura?and petechiae/purpura?

2.2. What is the most likely diagnosis of this What is the most likely diagnosis of this patient?patient?

Q1:Q1:What conditions will What conditions will

manifest manifest with fever and with fever and

petechiae/purpura?petechiae/purpura?

Fever and PetechiaeFever and Petechiae

Dengue fever & Dengue Hemorrhagic feverDengue fever & Dengue Hemorrhagic fever MeningococcemiaMeningococcemia Streptococcal pharyngitisStreptococcal pharyngitis Infective endocarditisInfective endocarditis Other viral infections: Infectious mononucleosis, Other viral infections: Infectious mononucleosis,

atypical measles, CMV infection and enteroviral atypical measles, CMV infection and enteroviral infectioninfection

Noninfectious causes: drug reaction, Henoch-Noninfectious causes: drug reaction, Henoch-Schonlein purpura, Hemolytic uremic syndrome Schonlein purpura, Hemolytic uremic syndrome and leukemiaand leukemia

Q2:Q2:What is the most likely What is the most likely

diagnosis of this patient?diagnosis of this patient?

Fever and petechiaeFever and petechiae

The differential diagnosis will involve an The differential diagnosis will involve an investigation of historical and investigation of historical and epidemiologic data, epidemiologic data,

etiologic agent and etiologic agent and

a study of the clinical course as to the a study of the clinical course as to the presence of prodromal manifestations, presence of prodromal manifestations, the progress of the rash and the the progress of the rash and the presence of pathognomonic signspresence of pathognomonic signs

1. 1. MeningococcemiaMeningococcemia

The patients with purpuric The patients with purpuric rashes often develop septic rashes often develop septic shock or DIC while patients shock or DIC while patients with macular or petechial with macular or petechial rashes are likely to have a rashes are likely to have a better prognosisbetter prognosis

Meningeal signs may be Meningeal signs may be present but meningococcemia present but meningococcemia can occur without meningitiscan occur without meningitis

Purpura necrotica Meningococcemia

MeningococcemiaMeningococcemia In the fulminating case, In the fulminating case,

death occur within hours death occur within hours from from overwhelming overwhelming toxemia and toxemia and uncontrollable shockuncontrollable shock – –(Waterhouse-Friderichsen Syndrome)

Bleeding into internal Bleeding into internal organs occurs from organs occurs from extensive capillary extensive capillary damage and DICdamage and DIC

Adrenal hemorrhageAdrenal hemorrhage

Prognostic indicators for Prognostic indicators for MeningococcemiaMeningococcemia

1.1. ShockShock

2.2. HyperpyrexiaHyperpyrexia

3.3. Rapid progression of petechial skin Rapid progression of petechial skin lesionslesions

4.4. LeukopeniaLeukopenia

5.5. Absence of CSF pleocytosisAbsence of CSF pleocytosis

DiagnosisDiagnosis Meningococcemia is suspected Meningococcemia is suspected

from the clinical picture of an from the clinical picture of an acute febrile illness with rapidly acute febrile illness with rapidly progressive purpura involving progressive purpura involving the skin and mucous the skin and mucous membranes esp. with membranes esp. with accompanying meningeal signsaccompanying meningeal signs

Direct film or smear from Direct film or smear from biopsy of a purpuric lesion on biopsy of a purpuric lesion on the skinthe skin

Definitive diagnosis is achieved Definitive diagnosis is achieved by positive blood cultureby positive blood culture

2. Dengue Fever and Dengue 2. Dengue Fever and Dengue Hemorrhagic FeverHemorrhagic Fever