FEVER WITH RASHES

DR. FAZAL

Age of child. Temporal relation of fever with rash. Site of onset—distribution—direction—

progression Morphology of rash Associated symptoms Is patient in shock ? PAST HISTORY

History taking in fever with rashes

Immunisation status. Contacts Immunocompromised ? Drug/food allergy Travel to endemic areas Animal/insect bite Joint pain Pica

PAST HISTORY

Full exposure in natural light. MORPHOLOGY-colour, size,

consistency,margins, surface characteristics.

DISTRIBUTION-flexor/extensor, sym/asymmetrical,centrifugal/centripetel.

If only exposed areas involved? Involvement of genitals/mucous membrane. Nikolsky sign

Examination of rash

Kopliks spot Forchheimer spots Palatal petechiae Pharyngitis. Strawberry tongue Fissuring of lips. Circumoral pallor. Coated tongue.

Oral examination

Lymph nodes. Joints. CNS involvement. Hepatosplenomegaly. Heart. Eyes

Associated systemic exam

Hb,TLC,DLC,ESR,Platelet count. Chest xray. Blood culture. Tourniquet test. Viral serology. TORCH screening. Urine analysis. Lumbar puncture. ECG, 2D echo.

Investigations

Maintenance of vitals. Temperature control. Isolation of patient Bed rest Nutritious diet Stop offending drugs (if any). Oral hygiene. Vit A. Antibiotics. Antihistaminics Specific treatment acc to etiologies

General management

MORPHOLOGY SMALL <0.5 CM LARGE >0.5CM

FLAT LESIONS

Normal texture macule patch

Indurated plaque plaque

ELEVATED LESIONS

solid papule nodule

Fluid filled vesicle bulla

Pus filled pustule pustule

LESIONS D/T EXTRAVASATION OF BLOOD

petechiae ecchymosis

Terminology of primary skin lesions

MACULOPAPULAR PURPURIC /PETECHIAL

Measles (rubeola) Infectious mononucleosis

Rubella Malaria

Roseola infantum (exanthema subitum/6th disease)

Rickettsial

Erythema infectiosum (5th disease)

Meningococcal

Kawasaki disease Infective endocarditis

Infectious mononucleosis Viral hemorhagic fever

Early meningococcemia

Typhoid

Dengue

Erythema marginatum

Typhus

Morphology of rashes…

VESICOBULLOUS NODULAR SCARLITINIFORM

Varicella Erythema nodosum Scarlet fever

Impetigo. Fungal Kawasaki ds

Enterovirus Pseudomonas Toxic shock syndrome

Meningococcal Atypical mycobacteria Staphylococcal scalded syndrome

Morphology of rashes

Drug Allergic Reaction

MEASLES

Paramyxovirus. IP—8 to 12 days. Period of communicability.

4—Rash—5. Rash starts from face &

behind ears. KOPLIKS SPOTS. Diagnosis mostly clinical

MEASLES

MACULOPAPULAR ERUPTION

KOPLIK SPOTS

- mild measles in people with partial protection◦Usually children vaccinated prior to age 12 months +/- coadministered immune serum globulin or

◦Persons receiving immunoglobulin. ATYPICAL MEASLES-Rash begins peripherally and moves centrally in persons receiving formalin inactivated measles.

MODIFIED MEASLES

Respiratory infections-otitis media (mc),croup,tracheitis,bronchiolitis.

Abdominal pain – appendicitis due to swelling of Peyer patches/hepatitis/gastroentritis

Pneumonia,Hecht’s pneumonia. Myocarditis,g’nephritis,thrombocytopenic purpura Encephalitis (most serious) Late onset: subacute sclerosing pan encephalitis

(autoimmune phenomenon) Activation of a tubercular focus. Diarrhoea, malnutrition. Febrile seizures (<3%). BLACK MEASLES.

MEASLES - COMPLICATIONS

No specific treatment Hydration, antipyretics Avoid intense light (for photophobia) IV ribavirin . Vitamin A . single dose of 2 lacs iu oral- >1 yr. 1 lac iu oral -6 m to 1 yr. if opthalmologic evidence –repeat dose next day & 4 wks later.

MEASLES - TREATMENT

INDICATIONS.-6 m to 2yrs hospitalised with measles & complications- >6 m not received vit A & with risk factors. immunodeficiency,clinical e/o vit A def,impaired intestinal absorption,moderate to severe malnutrition,migration from endemic areas.

vitamin A recommendations

RUBELLA

Rubella German measles/3 day

measles—RNA Togavirus IP—2 to 3 weeks. Most contagious-2 days

prior to 6 days after rash Winter-spring Prodrome Face - neck - trunk. Lymphadenopathy. Forchheimers spots(20%)

Thrombocytopenia (1/3000) Arthritis-clasically small hand joints Encephalitis(1/5000). Progressive rubella panencephalitis. Others – GBS, peripheral

neuritis,myocarditis.

Complications of rubella

Infection in utero: congenital rubella syndrome (CRS)◦ If infection in 1st trimester – 90% of fetuses

infected.◦ After 16 wks of gestation –defects uncommon

even if fetal infection occurs. Infants with CRS may shed virus in

nasopharyngeal secretions and urine for more than 1 year – can easily transmit virus

Congenital rubella syndrome

Features of congenital rubella syndrome: 1-Intrauterine growth retardation small for gestational age and failure to thrive 2-Nerve deafness3- Microcephaly and mental retardation4- Congenital heart disease (PDA, VSD) 5- Cataract, glaucoma, and cloudy cornea6- Thrombocytopenic purpura.7- Hepatosplenomegaly,osteopathy,interstitial

nephritis, pneumonitis.

Exanthema subitum. HHV-6,7. IP-5 to 15 days Children >6 months. NO PRODROME. Abrupt high fever. Fever resolution by CRISIS & LYSIS. Febrile seizures. Rash develops after fever dissipates-rainbow following the

storm Mainly on trunk-rash fades within 3 days. NAGAYAMA’S SPOTS Good prognosis

ROSEOLA INFANTUM/6th disease

Begins on trunk & spreads out

ROSEOLA

Febrile seizure (10% of pts) HHV-6 can cause meningoencephalitis or

aseptic meningitis Multiorgan disease can occur in

immunocompromised patients◦ Pneumonia◦ Hepatitis◦ Bone marrow suppression◦ Encephalitis

ROSEOLA - COMPLICATIONS

Chicken pox

Herpes virus varicellae IP- 10 to 21 days Papules-vesicles -crusting. Pleomorphic,flexor surface. Spreads centripetally,symmetrical,mucosa &

axilla involved,spares palm & soles,diminishes centrifugally.

Scab formation after 4-7 days. Fever rises with each fresh crop of rash Period of communicability is 2 days before and

7 days after lesions crusted over

Chickenpox

Dew drops on skin

Secondary infections (staph/strep) most common; may be life threatening with toxic shock syndrome/necrotizing fasciitis

Varicella gangrenosa – thrombocytopenia with hemorrhagic lesions

Pneumonia,Myocarditis/pericarditis. Hepatitis,Glomerulonephritis,Orchitis Arthritis Ulcerative gastritis Encephalitis (cerebellar ataxia may occur without

encephalitis) Reyes syndrome

VARICELLA - COMPLICATIONS

Primary varicella in pregnant woman fetal varicella infection◦ Low birthweight, cortical atrophy, seizures,

mental retardation, chorioretinitis, cataracts, intracranial calcifications

Children exposed in utero to VZV may develop zoster without varicella

Fetal varicella

◦ Occurs in newborns of mothers with varicella (not shingles) 5 days before or 2 days after delivery◦ Child born prior to maternal antibody response develops◦ Treat infants ASAP with varicella zoster immunoglobulin

Severe neonatal varicella

Oral acyclovir- indications◦ Healthy nonpregnant teenagers and adults◦ Children > 1 yr with chronic cutaneous or

pulmonary conditions◦ Patients on chronic salicylate therapy◦ Patients receiving short or intermittent courses

of aerosolized corticosteroids Dose: 80 mg/kg/day in four divided doses

for 5 days

Varicella – Treatment

VZIG (1 vial/5 kg IM) :◦ Pts on high dose steroids◦ Immunocompromised without a history of CP◦ Pregnant women◦ Newborns exposed 5 days prior to birth and 2

days after delivery◦ Neonates born to nonimmune mothers◦ Hospitalized premature infants < 28 weeks’

gestation

Varicella – Post exposure

ERYTHEMA INFECTIOSUM – 5TH DISEASE

Human parvovirus B19. IP-4 to 14 days. Preschool and young school age children. Prodrome minimal or absent Slapped cheek syndrome with circumoral pallor. Lacy reticular pattern on fading. Rash lasts for 1 to 3 weeks. Waxing and waning course. Spread is respiratory Initial viremia at 7-10 days; mild flu-like illness Patients are only contagious up to presence of rash

ERYTHEMA INFECTIOSUM – 5TH DISEASE

ERYTHEMA INFECTIOSUM – 5TH DISEASE

Complications◦ Arthritis: F>M, older>younger ◦ Aplastic crisis: usually not noticed in patients

with normal erythrocyte half-life BUT results in severe anemia in those with any chronic hemolytic anemia (rash follows hemolysis)

◦ Pregnancy: early miscarriage, late hydrops fetalis

◦ GLOVES & SOCKS SYNDROME-Papular/purpuric

ERYTHEMA INFECTIOSUM – 5TH DISEASE

Vasculitis of unknown etiology Multisystem involvement and inflammation

of small and medium sized arteries with aneurysm formation

More common among children of Asian decent

Usually children <5 years; peak 2-3 years. 3 CLINICAL PHASES-acute,

subacute,convalescent.

KAWASAKI DISEASE

CLINICAL DIAGNOSIS

ERYTHEMATOUS MACULAR ERUPTION - KAWASAKI SYNDROME

CONJUNCTIVAL INJECTION

STRAWBERRY TONGUE

ANGULAR CHELITIS

DESQUAMATION OF THE SKIN

Coronary artery thrombosis and coronary artery aneurysm(25%)

Myocardial infarction Myocarditis(50%). Congestive heart failure Hydrops of gall bladder Aseptic meningitis Arthritis Sterile pyuria (urethritis) Thrombocytosis Diarrhea Pancreatitis Peripheral gangrene

KAWASAKI DISEASE - COMPLICATIONS

ACUTE STAGE. IV Immunoglobulin (mechanism unknown)

◦ Single dose of 2 g/kg over 12 hours

Aspirin 80-100 mg/kg/day divided q 6hrs until day 14. CONVALESCENT STAGE. Aspirin 3-5 mg/kg od until 6-8 wks after illness onset. CORONARY ABNORMALITIES (long term therapy) Aspirin 3-5 mg/kg od +/- clopidrogel 1mg/kg max upto 75 mg/day, ACUTE CORONARY THROMBOSIS. prompt fibrinolytic therapy.

KAWASAKI DISEASE - TREATMENT

Aedes aegyptii-daytime,urban,collections of water.

Dengue like disease-chikungunya, o’nyong-nyong, westnile fever.

IP-1 to 7 days. Sudden onset of high grade fever. Frontal/retroorbital pain. Back break fever. C/F in first 2 days ,2-6 days,after 1-2 days of

fever.

DENGUE

Multiple types of dengue virus. Dengue 3 virus- severe clinical syndrome.. Relatively mild 1st phase with rapid clinical

deterioration & collapse after 2-5 days. Hepatomegaly may be seen. Positive tourniquet test. 20-30% - Dengue shock syndrome. 10%-gross ecchymosis/gastrointestinal

bleed

Dengue hemorrhagic fever

DENGUE HEMORRHAGIC FEVER. 1. Fever. 2. minor/major hemorrhagic manifestations. 3. thrombocytopenia ( <1lac). 4. objective evidence of increased capillary permeability (hematocrit increased by >20%). 5.serosal effusion(by CXR/USG). 6.hypoalbuminemia. DENGUE SHOCK SYNDROME. ABOVE + Hypotension/narrow pulse pressure(<20mm Hg)

WHO CRITERIA FOR DHF & DSS

GRADE 1- Fever + positive tourniquet test.GRADE 2- Spontaneous bleeding.GRADE 3-Circulatory failure.GRADE 4- Profound shock with undetectable BP

GRADES OF DHF

DF. Bed rest, supportive treatment, Aspirin C/I. DHF. 1. IVF NS>RL. 2. If pulse pressure <10mm Hg/elevn of hematocrit persists-plasma/colloid. 3. avoid overhydration. 4. serial hematocrit determin & vitals monitoring

TREATMENT

IP-7 to 14 days. Stepladder rise of fever (rare). Abdominal pain Hepatosplenomegaly m

Relative bradycardia. Coated tongue. Maculopapular rashes/rose spot in 25%

cases. Rose spot difficult to appreciate in dark

skinned.

Typhoid rash

Acute, self limited illness,oral transmission Epstein-Barr virus. IP-30 to 50 days. Clinical features Atypical lymphocytosis.

Infectious Mononucleosis

Mononucleosis Rash

Ampicillin rash.Gianotti crosti syndrome.

Major jones criteria. Trunk, upper arms,legs

never on face Maculopapular, raised edges

central clearing,circular shape Not itchy/painful.

Erythema marginatum

Erythrogenic toxin producing group A --hemolytic streptococci 1 to 2 days after pharyngitis Rash from neck- trunk- extremities,blanches on

pressure. Petechiae in linear form. More intense along elbow,axilla,groin creases. Fade in 4 to 5 days with desquamation 1st face

progressing downwards. Warm Sandpaper like skin White and red strawberry tongue Treatment –penicillin or erythromycin

Scarlet Fever

SCARLET FEVER – STRAWBERRY TONGUE

Neisseria meningitides. Usually sudden onset of fever,chills, myalgia, and arthralgia Rash is macular, nonpruritic, erythematous lesions,usually on extremities,relative sparing of child’s body surface. Petechial rash develops in 75% of cases• Complications: permanent CNS damage, deafness,

seizures, paralysis, cognitive deficits,fever, rash, hypotension, shock, DIC

Treatment: Pen G/ Cefotaxime/ ceftriaxone.

Meningococcemia

MENINGOCOCCEMIA

Superficial infection of the dermis Two types:

◦ Impetigo contagiosa◦ Bullous impetigo

Etiology◦ Group A ß hemolytic streptococcus◦ Coagulase positive S. aureus

Treatment : Erythromycin.

Impetigo

Multiple crusted lesion with erythematous halo with polycyclic edges. Spreads without healing.

Impetigo contagiosa

< 5 yrs. Staphylococcal exfoliatin Bullous lesions. Easy peeling of skin in thin sheets. Positive Nikolsky’s sign Diagnosis: Tzanck test, bacterial culture Treatment

Staphylococcal Scalded-Skin Syndrome

TOXIC SHOCK SYNDROME

Most common rickettsial infection in US Abrupt fever, headache, and myalgia Rash from extremities towards trunk Macules-petechiae Treatment

◦ Tetracycline◦ Doxycycline◦ Chloramphenicol

Rocky Mountain Spotted Fever

ROCKY MOUNTAIN SPOTTED FEVER

Enteroviruses◦ coxsackieviruses A and B◦ echoviruses

Vesicular lesions, may be petechial Associated with aseptic meningitis,

myocarditis

Hand-Foot-Mouth Disease

HAND FOOT & MOUTH DISEASE

LYME DISEASE

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