Fever with Rash

By Dr;Walaa Manaa

Types of rash.Enanthem:m.m.rash. Exanthems: skin rash

Exanthems

Macupapuler rashCommon infection:

Scarlet fever.Measles.

Geman measles.Roseola infantum.

erythema infectiosumEnteroviral infection.

Skin and allergic conditionSweat rashDrug rash.

uticarial rashPapuler urticaria

Erythema multiformie

Macupapul

er rash

1-rash is essential and diag. cannot made with out.

1-common inf.(scarlet-measles-g.measles-

ros.infuntum-eryth.inf.-rota virus inf).2-skin and allergic cond;

(sweat rash- drug rash urticarial rash-papuler urticaria-erythema multi forme

1-rash is not essential and diag. can made with out.

1-Infection (typhoid-IMN-ricketttsial

disease.2-rheumatic diseases

(JRA-SLE-Kawasaki)

Fever with rash:• May indicate a serious bacterial

infection in 20% of cases (e.g.menengococcal menengitis,HIb,,,,,,,,,)

• 80% of cases are caused by viral infection.

Fever with rash:1-very (varecilla) chicken pox &

menigitis.2-Sick scarlet fever & erysipelas.3-People small pox.4-Must measles.5-Take typhus.6-Entire enterica.7-good glandular fever.8-Rest relapsing fever.

Dangerous sings in fever with rash:

1-if associated with sever constitutional S&S.

2-if hemorrhagic.3-if is extensive.4- if associated with

shock or coma.

clinical history1-personal data

( Age-Gender-Ethnicity-Season - Geographic area)

2-Exposurescontacts (home, day care…) Travel, Pets, insects ,drugs ,Immunization

3 -Associated symptomsFocal (suggesting organ) Systemic (multisystem illness).

4-Features of rash (onset relative to fever-Progression-

Location- distribution Pain or pruritus)

5-Past history(Medical and surgical history-Growth and

development Recurrent infectious illnesses)

6-Family history.

clinical examination1-Degree of toxicity

2 -Characteristics of rash(Macular-Papular-Maculo papular Petechiae or purpura)

Vesicles, pustules, bullae Nodules. Diffuse/localized erythroderma .

3-Associated enanthem

Buccal and genital mucosa Palate Pharynx and tonsils

4 -Associated findings Arthritis, ocular, GI, cardiac…

Viruses Bacteria OtherMaculo/papular rash

Measles, rubella, HHV-6EBV, HBV, HIV, enterovirus

GABHS (scarlet fever)…

Salmonella, Lyme,Mycoplasma pneumoniae

Rickettsia

Vesicular, bullous

VZV, HSV, EchovirusCoxsackievirus A, B

Impetigo

Petechial CMV, enterovirus, EBVHemorrhagic fever, VZV

Sepsis (N.men, S.pneu,Hib)Rat bite fever (S. minus)

Rickettsia

Diffuse erythroderma

Dengue scarlet fever, TSS C. albicans

Urticarial rash

EBV, HBV, HIV,Enterovirus

M. pneumoniae

Case presentation

History:

9 mo old girl, good general health conditionProgressive fever for 3 days (max. 39.5 C)Coryza, exudative conjontivitis,severe cough and irritability

No diarrhea, no vomitingNo recent travel, no petsAttends day care 2d/w Confluent maculo-

papular rash all over the body

Clinical case 1

MeaslesAcute viral infection

Human being is the only reservoir

Caused by a paramyxovirus

Very contagious (reach 90% ofsusceptible contacts within a family.Respiratory route)

Rubeola.*Viral disease.

*I.P. 2W*Age >6-9 ms??

*fever:rises gradually in 1st 4dayes reach 40 with apperarace of rash.

Then after 2days decline to normal ( after rash reach to feet).

Fever associated sevse catarrhal manifest.(rhinitis—conjuctivitis—cough).

No measles with out cough.

The rash starts behind the ears and on the forehead at the hair line

•The spread of the rash is centrifugal (head to legs)

Diagnosis

Clinical Serology Viral culturePCR

Characteristic features:Koplik s spotes;

*Appeare 3rd day.i.e.one day before the rash.

*White grains of sand surrounded by red areola.

*On oral mucosa oppositeto the lower molar teeth.

*Remain 1-2 days.

*Disappear after onset of rash .

complications

1-pneumonia (viral or commonly 2nd bacterial)50%.

2-encephalitis 1-accompany the illness(viral encphalitis.

2-2-3 weeks after the illness (allergic enchelalitis). 3-Several years later (SSPE).

3-Black measles (purpuric rash+hgic manifestation.)

4 -Myocarditis and pericarditis

5-Acute otitis media (10-15%).

(more severe in adults)

Treatment*No specific antiviral treatment.

* Vaccination within 72h after contact.

*Immunoglobulins within 6 days after contact in immunocompromised and < 1 y old children.

Important notice… *Eradication of measles can be obtained if >95% of the

population is immune.

*Measles is endemic if 15-20% of the population is susceptible

*Epidemics can occur if > 25% of the population is susceptible

( without fear, vaccinate your children) «No evidence for measles, mumps, and rubella vaccine-

associated inflammatory bowel disease or autism in a 14-y prospective study »

et al. Lancet 1998

ان- • يمكن ال لكن بالعينين التهاب بدون الحصبة تأتى ان يمكنالحلق فى موجود الفيروس الن كحة بدون تأتى

لذلك- • والحلق االنفية باإلفرازات موجود الحصبة فيروسباالنف ملح محلول نقط باستعمال ينصح

لذلك- للعمى تؤدى قد بالعينين لمشاكل عرضة الحصبة مريضمتكررة بصفة ملحى وبمحلول بالماء العينين غسل من البد

لمدة يوميا مرتين حيوى مضاد مرهم وتنصح ايام 5ووضعدور من له لما الحصبة لمرضى أ فيتامين باعطاء الصحة وزارة

وايضا العينين مشاكل من الحماية فى الوفاة هام نسبة يقللالى الحصبة كاالتى% 50من والجرعات

من يومين 50,000شهور 6اقل لمدة يوميا وحدةسنة : : 6من يومين 100,000شهور لمدة يوميا وحدة

سنة : من يومين 200,000اكبر لمدة يوميا وحدةكجفاف أ فيتامين نقص اعراض عندهم اللى المرضى فى

بعد .. ثالثة جرعة اعطائهم يتم و اسابيع 4-2الجلد

فى • بالجفاف لالصابة عرضة الحصبة مريض ) ينصح ) لذلك كمضاعفات االسهال حاالت

ومحلول الجيدة والتغذية السوائل من باالكثارعند بالوريد ومحاليل الجفاف معالجة

الضرورة

وقرح- • الفم لفطريات معرض الحصبة مريضبخاخ : + . سى بى بى جل دكتارين الفم

بالك - خلىوبينهج حصبة عنده عيان pneumonia: لو

وبيتشنج حصبة عنده طفل encephalitis or febrile: لوconvulsion

ومدروخ حصبة عنده عيان dehydration or: لوencephalitis

عياط : مبطل ومش حصبة عنده طفل otitis mediaلوبالبطن علو شديد الم وجاله حصبة عنده : يان

appendicitis (right iliac fossa) حوالى عمره شخص الزهايمر 30لو وجاله : سنة

subacute sclerosis pan encephalitis البصر وفقد الحصبة عنده عيان السبب لو انت يبقى

أ فيتامين اديتش وما بالعينين اهتمتش ما عشان

لمدة • مؤقتا المناعة تضعف العدوى 6الحصبة بعد اسابيعmeasles virus suppresses cell mediated immunity

راى- • عشان للحرارة كخافض االسبرين استعمال ممنوع طبعاسيندروم

نمنع- • عشان حيوية مضادات نستخدم 2ry bacterialوالزمinfection

فيروس- • سببه يكون قد للحصبة كمضاعفات الرئوى االلتهاببكتيرى سببه يكون قد أو نفسه 2ry bacterialالحصبة

pneumonia تزييق معاه الفيروسى الرئوى االلتهاب ان بينهم ما الفرق

sibilant rhonchiبالصدر بالصدر تزييق يعمل ما عمره البكتيرى الرئوى االلتهاب انما

اسئلة 3فيه االول نتيجة: السؤال يتحسن الذى المريض هو من

حالته تسؤ الذى المريض هو وما بالحصبة اصابتهبالحصبة؟ اصابته نتيجة

الثانى الرئوى: السؤال االلتهاب تعالج كيفالحصبة؟ عن الناتج السحائى وااللتهاب

الثالث تضعف: السؤال الحصبة ان المعروف منلمدة تطعيم 6المناعة من االطفال يمنع فهل اسابيع

و االطفال تلك live attenuated vaccinesشلل خاللالفترة

الثانى السؤال treatment of measles pneumonia andاجابةencephalitis is mainly symptomatic with addition of antibiotics to

prevent secondary bacterial infection هذه فى الريبافيرين تجربة تمبعد يعتمد لم لكن الحصبة فيروس ضد جدا فعال انه وثبت الحاالت

العالمية الصحة منظمة من

الثالث السؤال measles not contraindication to live attenuatedاجابةvaccines but it is recommended to delay vaccination untill the acute febrile illness ceased severe immunuodifieciency is absolute contraindication to live attenuated vaccines

الحصبة : , الدرن هو الحصبة مع يسؤ الذى المرض االول السؤال اجابةالى فتؤدى المناعة مع activation of TBتضعف يتحسن الذى المرض

هو minimal change nephrotic syndromeالحصبة

Clinical case #2History :

7 y. old boy, good general health conditionSudden onset of sore throat since 24h andfever at 39C. Abdominal pain and

1 episode of vomiting No conjuntivitis ,

No rhinitis , No hoarseness

No cough Attends primary school, no recent travel

Scarlet fever - ScarlatinaScarlatina is caused by erythrogenicexotoxin producing strains ofGroup A ß-hemolytic Streptococci

Common among school-age children(very unsual in < 2 y old)

5-10% of healthy carriers

Transmission by direct contact or respiratory droplets

Incubation: 2 to 5 days

Untreated cases remain infectious for aprolonged period, unlikely after 24h ofappropriate antibiotic therapy

Clinical features*Abrupt onset

*Fever—39 C *Sore throat

*Abdominal pain*Variable pharyngitis

*Tender lymphadenopathy

Rash:Appears in1st or 2nd day Soon become generalized

(gooseflesh=sandpaper)Flushed face+cicumoral pallorRemaine3-7 dayFade with branny desquamationUsually involves palms and soles

Thick, white layer throughwhich red papillae protrude

(white strawberry tongue)

Peeling after several days(red strawberry tongue)

Pintpoint petechiae in the flexures produce a linear purpuric pattern (pathognomonic) = Pastia’s lines

After a week, the rash typically starts to desquamate,

particularly on the hands and feet

Local: Otitis media Pharyngeal abcess

AdenitisInvasive: Sepsis

Non suppurative : Glomerulonephritis

rheumatic fever erythema nodosum

Complications of GAS infection

Diagnosis: Clinical Rapid strep test

Culture ASLO

Treatment: Antibiotics ( penicillin)

A 15-month-old child presents to your officewith a mild fever, and an intense, red rash on the cheeks with circumoral pallor. What is the most likely etiology of this febrile exanthem?

(A )enterovirus 71(B )adenovirus

(C )parvovirus B19(D )rubeola virus

(E )coxsackievirus A16

Clinical case #3

«Slapped cheek disease » fifth disease, erythema infectiosum

Caused by Parvovirus B19

Discovered in 1975

Causes spring epidemics in children 4-10y (attack rate 40%)

Often asymptomatic- soSeroprevalence of 50% at age 15

I.P……………..4-14 daysStage I

Mild prodromal illness low grade fever

headache GI symptoms

Stage II (+3-7 days) Erythematous facial exanthem

(slapped cheeks ) Stage III (+1-4 days)

Lacy maculo-papular exanthem on the trunk and extremities. May be pruritic, evanescent ,

Arthropathy (adults >> children,female >> male

Children are infectious during the prodromal stage and do not shed virus at the time of the rash anymore

===Control of epidemics very difficult

Complications of parvovirus B19

1-Erythrocyte aplasia

(by direct infection of the red cell precursors)

2-Intrauterine infection(hydrops fetalis (5% of infected

foetus),rash, hepatomegaly, cardiomegaly and anemia)

Diagnosis Clinical

Serology (arthritis , red cell aplasia )..

Treatment No specific treatment

Parvovirus B19

Clinical case #4

History: 6 month old boy,

No past medical historyNo prodromesFever 40 C of sudden onset Febrile convulsion

3 days later the fever abates and widespread macular rash

Roseola infantum,exanthem subitum

« sixth disease «Caused by Human herpes virus type 6 (HHV-6B) in rare cases by HHV-7

Discovered in 1988> 95 % of children are affected

Almost all cases between 4 mo and 2 years

Sporadic illness (rare outbreaks)

No seasonal distribution

Reactivation possible (immunosuppressed persons)

Clinical manifestationsOften asymptomaticMild prodromes (rhinorrhea, diarrhea)Sudden onset of fever (39-40C) lasting 3-5 days

Rose-coloured macular rash,present for few hours up to 2daysAffects the neck and trunk extending to theface and proximal extremities

No pruritus, no desquamation

Associated with febrile convulsion

Diagnosis •Clinical •Serology

•PCR

Treatment •Symptomatic

(antipyretics)

Clinical case #5History :

5 y old boy, no special past medical history

Low grade fever (38.30C) for 48 h

Attends school

No travel historyNo pets

Vesicular rash on the trunk and face

A7-year-old unimmunized child presents with fever and vesicular rash. You notice about 300lesions, some of which were crusted. You suspectvaricella infection. Which of the followingis a TRUE statement about varicella?

(A ) 5–7 It has an incubation period of days.(B )The rash is confluent, centrifugal, and

pustular.(C ) It is associated with Koplik spots.

(D ) There is a high risk of shingles.(E )It can cause visceral dissemination in

the immunocompromised host.

(E )The rash of varicella follows an incubationperiod of 10–21 days. There is the onset of a very pruritic rash, with crops of lesions that begin as papules and progress to vesicles and finally crusted scabs. Typically, all three stages of skin lesions are identified on clinical examination. Fever usually is mild to moderate. Whilea generally self-limited and benign course is noted, severe disease may occur occasionally in the otherwise healthy host, especially adolescents and adults. A progressive and severedisease with visceral dissemination is seen in 30%–50% of children with lymphoproliferative malignancies, solid tumors, or posttransplantation with the development of hepatitis,encephalitis, and pneumonia. Fatal disease has also been reported in those treated with highdose corticosteroids and in those with other defects of T-cell function. (Long, 1022–1024

Caused by varicella/zoster virus

Most common exanthematous disease of childhood

Humans are the only reservoirAffects 90% of children between 1 to

14 years

Highly contagious (>90% in householdcontacts)

Contagiosity: 2 days before to 5 daysafter the rash

Occurs in late winter early springLess common in tropical climates

Incubation period 14 days (10-21)

Replication at the site of infection, primary viremia which establishes replication in the reticulo endothelialsystem .

A secondary viremia occurs after about a week with disseminates to the skin.Establishment of latency in sensory ganglia

reactivates years later to cause zoster

Prodromes with 1-2 days oflow grade fever

•Erythematous papules •Vesicules

•Pustules •Crust

Spread from the trunk to theface, neck and extremities

Pruritus+++ Mucous membranes can be Involved

The hall mark of the varicella rash is the simultaneous presence of lesions of different stages

Diagnosis

•Clinical •Serology

•Immunofluorescence

•Culture

•PCR

Increase with age

1-PneumoniaRare in children, high mortality in immunocompromised host)

2-Cerebellar ataxia (1/4000 in <15 y)Develops 7 to 10 days into the disease,excellent prognosis

3 -Transvere myelitis, Guillain-Barre sy.

4 -Hemorrhagic varicella Thrombocytopenia

Complications

5-Superinfections

locally with S. aureus or GABHS cellulitis

systemic with GABHS sepsis, necrotizing fasceitis

Strep. TSS

6-Reye syndromePersistant vomiting, decreasing mental status, liver failure.Associated with salicylate-containing products

Avoid aspirin in varicella!!!

Complications

7-conginital infection ( 2% ,18-22 w of gestation)

Small size, cutaneous scarring, limb hyplasia, microcephaly,cortical atrophy, chorioretinitis,

cataracts.…

8-Perinatal infection

5 days before to 2 days after birth(high mortality without treatment

30%)

Treatment

Secondary prevention

Must be administered by 96h after exposure (or better if < 72h)

Primary and secondary prevention by a vaccine

You are counseling a primigravid woman who has been found to be rubella non immune on prenatal laboratorye valuation. She asks you if her fetus is at risk for malformations. When is maternal infection with rubella virus most commonly associated with congenital defects?

(A )in the first 4 weeks of gestation(B )in the second month

(C )in the third or fourth month(D )in the last trimester

(E )anytime during pregnancy

Clinical case #6

(A )Congenital malformations, stillborns, and abortions all have been reported with rubella infection during pregnancy. The congenital rubella syndrome consists of ophthalmologic, cardiac, auditory, and neurologic abnormalities with rates as high as 85% if infection occurs in the first 4 weeks of gestation, decreasing to

20%–30% during the second month, and 5% during the third or fourth month. These infants may continue to excrete rubella virus for 1 yearor more after birth and pose a risk of infectionfor susceptible hosts. (American Academy ofPediatrics, 574)

German measles*Viral disease

*IP……2-3 W*Fever:

Mild remain for 1-2 day it may absent ( cold measles)

*Rash:Start in 2nd -3rd day on face----spread to trunk rapidly cover all body in 24 hrsClear completely in 3 days

*Characteristic sign Post auriculer –occipital-post cx LN

Complication:1-Usually absent in children.

2-Congenital rubella synd(cataract+CHD)

An 18-year-old boy presents with acute severechest pain. EKG and enzyme studies confirman acute myocardial infarction. Cardiac catherization reveals a coronary artery aneurysmwith thrombosis. Which constellation of symptomsin his past could explain this finding?

(A )conjunctivitis, fever, cervical lymphadenopathy

(B )meningitis, conjunctivitis, pallor(C )cervical lymphadenopathy, hepatitis, rash

(D )fever, irritability, pancreatitis(E )hepatosplenomegaly, rash, conjunctivitis

Clinical case #7

History: 20 mo old boy

High fever (39.50C) for 5 days remittent with several spikes each dayIrritable No cough

Physical examinationBad general conditionPolymorphous rashconjunctival injectionfissured lipscervical lymphadenopathy (>1.5 cm)No travel historyNo petsVaccination: OK for the age

First described in 1967

Incidence: 67 cases /100’000 in Japan5.6 cases/100’000 in the USA

85% in children < 5 years (peak 18-24 mo)Rarely occurs in adolescent, adults or children < 6 mo M/F ratio 1.4:1

Occurs often in late winter and spring

Etiology: UKNOWN

Pathophysiology: « Superantigen theory «

causing an intense vasculitis

VASCULITIS

KAWASAKI disease

92%

65%

75%

More than 5 days

Non purulent

77%

Associated findingsAseptic meningitis (25%)Arthritis and arthralgia (20-40%)DiarrhoeaHydrops of the gallbladder

Differential diagnosisMeasles, scarlet feverTSS, Steven-Johnson sy,Juvenile rheumatoid arthritis…

LaboratoryHigh ESR and CRPSterile pyuriaHigh platelet count (second week)

4

ComplicationsCoronary aneuvrysm

Prognosis75% no sequelae, 25% coronary

abnormality (without treatment),1-2% mortality in the acute phase

1-Immunoglobulins 2g/kg body weight.

2-Aspirin 80-100 mg/kg/day duringthe acute phasethen 3-5 mg/kg/day for months when fever subsides

Treatment

A13-year-old female presents to the emergency department with a 3-day history of fever above (40°C); vomiting; diarrhea; and diffuse erythematous rash. She is found to have orthostatic hypotension. Laboratory evaluation reveals decreased platelets and elevated liver and renal function tests. The mother of the child informsyou that the child is currently menstruating. You suspect that this child has a toxin mediated infection. What is the most likely etiology of this toxin mediated infection?

(A )Streptococcus pyogenes(B )Staphylococcus aureus(C )Neisseria gonorrhoeae

(D )Streptococcus agalactiae(E )Shiga-toxin-producing Escherichia coli

Clinical case #8

(B ) Manifestations of staphylococcal toxic shock syndrome, , which include fever mental status , changes

, , conjunctivitis diffuse macular erythroderma and multiple , organ failure are caused by a toxin elaborated by the

. staphylococci rather than by tissue invasion of the organism -1) -1(, The name of the toxin is toxic shock syndrome toxin TSST and is produced by . S aureus The organism usually can be

cultured from skin or mucous membrane and only rarely from . the blood It has been recovered from the vagina and has been

, associated with the use of tampons especially those designed . to be changed infrequently Streptococcal toxic shock

syndrome is cause by ) (. S pyogenes group Astreptococcus The incidence , is highest among young children particularly those

. with concomitant varicella The organism can be isolated from 50% blood about of the time.

Both N gonorrhoeae and S agalactiae can be found in the genital tract (the former as a pathogen and the latter as normal flora); neither is associated with toxin-mediated disease. Shiga toxin produced by E coli causes diarrhea and can be associated with hemolytic uremic syndrome. (Long, 110–112; American Academy of Pediatrics, 660–661)

Clinical case #9

Allergic skin disease

1-Miliaria

-Common inflammatory diseases*.

-Sweet duct obstructions.

-Hot weather.

- fine papule with intense erythema, vesiculation may occur(miliaria crystallina).

-Ttt ----cooling + removal of excessive clothes.

2-Drug rash

3-Urticarial rashWheals +itchy

-Delayed hyper sensitivity reaction to insect bite fleas +mosquitoes.

-Face and scalp are spared. -Itchy.

-DD with scabis.

4-papular urticaria

Erythema multiformisIs hypersensitivity reaction to varities of causes (drugs-infection-toxins ).

*skin only.*extensor surface of extremities

.Appear in croops in up to 3 weeks.Palm and sole are affected.

*pathognomonic --targit lesion*not itchy

Heal with pigmentation (hypo or hyper)

erythema multiforme minor

erythema multiforme major

*Serious form affecting skin and m.m.* Start sudden by fever chills

*Dominant lesion bullous at skin and m.m.upturehealing in 1-4- w.

*Oral lesions are painful.*Ocular lesions serios complicatios.

*2ndry bacterial infection may result in seticemia and death .

Stevens-Johnson syndrom

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