Fever and RashDJATNIKA SETIABUDI

Tropical Medicine Block/System Medical Faculty Padjadjaran University

Introduction Common problem in clinic

Wide range of severity : self limited disease life-threatening

Wrong 1st suspicion fatal outcome

Knowledge of differential diagnosis !!!

Differential Diagnosis (1)Past history of infectious disease and immunizationType of pro-dromal periodFeature of the rashPresence of pathognomic or other diagnostic signsLaboratory diagnostic tests

Differential Diagnosis (2)Feature of the rash :Category: - macular or maculo-papular - papulo-vesicular - petechial or purpuricCharacter : discrete or confluentDistributionDurationThe appearance associated with fever?

MORBILLI(Measles; Rubeola) Acute infection, contagious, caused by morbilli Virus ( Famili Paramyxoviridae) 3 stadia : Prodromal Erupstion Convalescens Endemic in developing countries Effective imunization program cases decreasing prone to older age group

Pathology Lesion particularly at : - Skin - Mucous membranes : respiratory : nasopharyng, bronchi digestive : oral cavity, intestine - Conjungtiva Serous exudate, mononuclear cell predominant

Clinical manifestations Incubation period : 10 12 days Stadium prodromal : - Coryza, Cough, Conjungtivitis - Koplik spots - Fever Stadium eruption : - High fever : 40 40,50C - Typical rash: maculopapular eritromatosus Head truncus extremities Stadium convalescens: - rash : hyperpigmentation macule/squama - sign and symptoms resolve

Diagnosis

Anamnesis : - symptoms - history : - contact - imunization

Clinical signs: typical

Laboratorium : - leukopenia, - relative lymphocytosis

Complication Pneumonia / Bronchopneumonia ; Otitis media CNS : - meningoensefalitis - Subacute Sclerosing Pan Encephalitis Persisten diarrhea protein lossing enteropathy Exaserbation of TBC Keratoconjunctivitis blindness Secondary bacterial infection of skin Myocarditis Noma

Prognosis Particularly good prognosis

CFR decreased

Mortality caused by complication

Treatment Symptomatic

Supportive

Vitamin A : Unicef/WHO reccomendation

Management of complication

Prevention Active immunization: - Measles vaccine - when ? 9 months old - booster: 15 months --> MMR

Passive immunization

RUBELLA (German Measles) Acute infection, contagious, caused by rubela virus (family Togaviridae) prodromal sign : + / - Rash : short periode 3 days Typical sign: lymphadenopathy post auricular suboccipital posterior colli Problems in pregnant women Congenital rubella Syndrome

Clinical Manifestation Incubation period : 18 + 3 days

Mild prodromal sign: - mild fever - adolescent : more severe

Rash : maculopapular face sentrifugal 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 Glaukoma - chorioretinitis Cardiac : Septal Defect PDA

Neurologic : Meningoencephalitis Microcephaly mental Retardation

Auditoric : sensorineural deafness

Exanthem 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 ( + 10 days ) Most common in 6 18 months old Fever - abruptly high ; 39,4 41,20C - Duration: 1 5 days ( mostly 3 4 days ) - Convulsion can occur Mild clinical sign : - mild pharyngitis and coryza Rash : not specific macule / maculopapular ; rose colour : chest > exremities and neck face Appear while temperature has return to normal Disappear on 1 2 days with normal skin

Prognosis Particularly good prognosis

Bad prognosis : - hyperpyrexia with persistent convulsion

Treatment Symptomatic

Supportive

Prevention : ?

SCARLET FEVER (SCARLATINA) Grup A beta-hemolytic Streptococcus pyrogenic toxin (erytrogenic toxin) Clinical manifestation : - Incubation period : 1 7 days (mean : 3 days) - Acute symptoms: high fever headache vomiting- chills - Signs: severe pharyngitis hyperemis edema eksudate- dysphagia - Circum oral pallor dan Pastia lines - white strawbey tongue desquamation red strawberry tongue

Typical rash: Reddish macule / papule blanching on pressure Firstly on axilla, groin and neck 24 hours all of body Severe disease : miliaria sudamina Petechiae can occur Desquamation occur from end of 1stweek to 6th week of disease

Diagnosis

History and physical examination

Pharyngeal swab : bacterial culture

Serologic : ASTO/ ASLO/ ASO Complete blood count : leukositosis CRP increased or (+) : not specific

Complication Local spread / per continuitatum: - Sinusitis Otitis media - Mastoiditis - Retro / para parapharyngeal absces - Bronchopneumonia - Servical adenitis

Hematogenic spread: - Meningitis Osteomyelitis Arthritis (septic)

Non-suppurative (late) complication: - Acute rhematic fever - Acute Glomerulonephritis

Treatment Antibiotics : - Penicillin group - Allergy to penicillin : Erythromycin lincomycin Clindamycin- Cephadroxil

Symptomatic

Supportive

Management of Complication