FEVER and RASH

SYARIFAH HANUM P
FEVER AND RASH

Definitions

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

Enanthem: Eruptive lesions on the
mucous membranes.

ETIOLOGY
INFECTION
Virus:
Classic viral exanthem: Measles, Rubella, VZV,
Parvovirus, Roseola
Others: HSV, EBV, Enterovirus, Dengue
Bacteria: Scarlet fever, Staphylococcal
infection (sepsis, 4S,toxic shock
syndrome), Meningococcemia, Typhoid
Mycoplasma
Rickettsial infection
NON INFECTIOUS
Reactive erythema: erythema multiforme,
urticaria, serum sickness, erythema marginatum
(acute rheumatic fever), erythema chronicum
migrans (Lyme disease)
Hypersensitivity syndrome: morbilliform drug
eruption, Stevens-Johnson syndrome, toxic
epidermal necrolysis, drug reaction w/
eosinophilia and systemic symptoms(DRESS)
Vasculitic diseases and purpura: purpura
fulminans, Kawasaki disease, hypersensitivity
vasculitis

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?
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
TOPICAL TREATMENTS AND PRODUCTS
Allergy? Masking effect?

IMMUNOSUPPRESSION
Risks for localized cutaneous infection and
systemic infection

EXPOSURES
To sick persons? Animals? Wildlife?
TRAVEL
To certain endemic areas? Foreign travel?

PHYSICAL EXAMINATION
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
DIAGNOSTIC TESTS
To help with diagnosis (if necessary)
Needs knowledge about:
- Sample needed
- Technique
- Transport/culture media
- Special condition if necessary
Classic Childhood Exanthems

I.Measles (Rubeola)
II.Scarlet Fever
III.Rubella (German measles)
IV.Filatow-Dukes Disease
V.Erythema Infectiosum
VI.Roseola Infantum
MEASLES/RUBEOLA/CAMPAK
Paramyxovirus
At Risk: Schoolage children who escaped
vaccination
Incubation Period: 7 18 days
Infectious Period: 1-2 days prior to prodrome
to 4 days after rash onset
Highly Contagious!


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 to
the 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

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)
Measles: Complications

2007 - 197,000 measles deaths
Otitis Media (7-9%)
Pneumonia (1-6%) severe in children <5yo
Encephalitis (1 in 1000-2000) fatal in 10-15%,
worse in adults > 20 yo
Blindness due to poor nutrition (Vit A def) and
measles infection
Subacute Sclerosing Panencephalitis (SSPE)
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
SCARLET FEVER/FEBRIS
SCARLATINA
Erthrogenic and pyrogenic exotoxin-
producing Group A beta-hemolytic
streptococci
Usually pharyngeal source, but occasionally
cutaneous infection
At risk: < 10 yo, peak 4-8yo
> 10 yo have lifelong antibodies to exotoxins

Incubation Period: 24 days
Infectious Period: during acute infection,
gradually diminishes over 3 weeks
reduced by good handwashing
clinical features

Abrupt onset fever, headache,
vomiting,malaise, sore throat
Enanthem
Bright red oral mucosa
Palatal petechiae
Strawberry tongue (initially white coating
appears and then on 4-5th day,
reddened,edematous papillae prominent)
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
Pastias lines
Scarlet Fever Desquamation

Desquamation of palms, soles, knees,
elbows
10 ds later, can last up to one month
Scarlet fever
Scarlet fever: Complications

Suppurative Complications
Otitis media
Sinusitis
Peritonsillar/Retropharyngeal Abscesses
Cervical Adenitis
Scarlet Fever: Complications

Nonsuppurative Complications
Rheumatic Fever
Poststreptococcal Glomerulonephritis
(Nephritigenic strains types 12 and 49)
Pediatric Autoimmune Neuropsychiatric
Disorder with Group A
Streptococcus(PANDAS) abrupt OCD
behaviors associatedwith mild pharyngitis
Scarlet fever
Scarlet fever
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-
5 days after rash onset
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

Exanthem:
- Starts on face and fades from face in 24 hours
- Notable feature appearance rapidly changes
in few hours
- Pink-red lesions seen as opposed to purplish
red lesions seen with measles
Diagnostic testing IgM in acute serum or
serial IgG in acute and convalescent sera
Complications

Generally benign disease
Arthralgias/arthritis in older patients
Peripheral neuritis, encephalitis, TTP rare
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
4th Disease = Filatow-Dukes
Disease

1900
Controversial and initially diagnosed
basedupon clinical and morphological
examination
No lab facilities to allow proper classification
1979 epidermolytic exotoxin-producing
Staph aureus causing erythematous cellulitis
then exfoliative dermatitis
ERYTHEMA INFECTIOSUM (5
th
-
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
Clinical Features

Over 50% of infections are asymptomatic
Prodrome: Mild fever (15-30%), sore throat,
malaise
Adults flu-like symptoms,
arthralgias/arthritis (potentially chronic, more
common in women)
1st Stage

Day #1
Slapped Cheek
Contagious only during this stage
2nd Stage

Day #2
Erythematous maculopapular eruption
Extensor surfaces
of extremities
3rd Stage
Day #6
Reticular pattern (pathognomonic)
Central clearing
Lasts 9-11 days
Complications

Result of viral infection of erythrocyte precursor
cells
Monitor patients at risk for transient aplastic
crisis
pRBC Transfusion as indicated
Hydrops fetalis (severe anemia causes high
output cardiac failure with fetal death rate of 1-
5%)
Raynauds Phenomenon immune-mediated
endothelial damage causes vasoconstriction
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

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 shed
into saliva throughout life; asymptomatic
persistent infection
Clinical Features

High fever for 3-4 days
Otherwise wellappearing 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?
Exanthem
- Erythematous maculopapules 2-3mm
- Rarely coalesce
- Initially present on trunk
- Blanches
- Benign disease usually without
complications/sequellae
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
Enterovirus rashes


Hand-foot-mouth disease
Herpangina
Nonspecific eruptions
HAND FOOT AND MOUTH
DISEASE

Typically due to Coxsackie 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
HERPANGINA

Coxsackie A viruses
At risk: young children
Prodrome: Fever, sore throat
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 morbiliform
eruptiom
4-6 days after onset of fever
Convalescence rash: purpuric eruption on hands,
forearms, feet, legs
DENGUE HEMORRHAGIC FEVER
Similar with DF
Sometime with hemorrhagic manifestation:
purpura, ptechiae, ecchymoses
DHF
Seorang anak perempuan berusia 2 tahun dibawa
ibunya ke RS YARSI karena demam dengan
bintik-bintik merah. Sejak 2 hari yang lalu anak
tersebut demam tidak tinggi dan sehari sebelum
ke rumahsakit keluar bintik-bintik merah mulai
dari muka yang kemudian menyebar ke seluruh
tubuh. Tidak didapatkan keluhan yang lain. Anak
belum pernah immunisasi sejak lahir. Pada
pemeriksaan fisik didapatkan frekuensi nadi
100x/menit, frekuensi napas 28x/menit, suhu
tubuh 37,80C, terdapat ruam makulopapular
tersebar di seluruh tubuh dan pembesaran
kelenjar limfe oksipital multipel.
Seorang anak laki-laki berusia 6 tahun dibawa ke puskesmas
karena mimisan. Mimisan sudah berhenti ketika sampai di
puskesmas. Anak tersebut juga menderita demam yang
sudah berlangsung 3 hari, demam tinggi sepanjang hari
dengan 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, frekuensi
nadi 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. Hasil
pemeriksaan laboratorium sbb: jumlah leukosit 2300/L,
hematokrit 38 vol%, jumlah trombosit 125.000/L