2 fever and rash

7/25/2019 2 Fever and Rash

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Fever and RashFever and Rash

DJATNIKA SETIABUDIDJATNIKA SETIABUDI

Tropical Medicine Block/Syse!Tropical Medicine Block/Syse!

Medical Fac"lyMedical Fac"ly

#ad$ad$aran Universiy#ad$ad$aran Universiy


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Inrod"cionInrod"cion

Common problem in clinicCommon problem in clinic

Wide range of severity :Wide range of severity :

self limited diseaseself limited disease life-threateninglife-threatening

Wrong 1Wrong 1ststsuspicionsuspicion fatal outcomefatal outcome

Knowledge of differential diagnosis !!!Knowledge of differential diagnosis !!!


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Di%%erenial Dia&nosisDi%%erenial Dia&nosis '()'()

1.1. Past history of infectious disease andPast history of infectious disease and

immuniationimmuniation

.. "ype of pro-dromal period"ype of pro-dromal period

#.#. $eature of the rash$eature of the rash

%.%. Presence of pathognomic or otherPresence of pathognomic or other

diagnostic signsdiagnostic signs

&.&. 'aboratory diagnostic tests'aboratory diagnostic tests


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Di%%erenial Dia&nosisDi%%erenial Dia&nosis '*)'*)

Fea"re o% he rash +Fea"re o% he rash +

Category:Category:

-- !ac"lar or !ac"lo,pap"lar!ac"lar or !ac"lo,pap"lar::

(orbilli) *ubella) *oseola infantum) +carlatina(orbilli) *ubella) *oseola infantum) +carlatina

-- pap"lo,vesic"larpap"lo,vesic"lar::

varicella) herpes oster) variolavaricella) herpes oster) variola

-- peechial or p"rp"ricpeechial or p"rp"ric: meningococcemia) ,$: meningococcemia) ,$

Character : discrete or confluentCharacter : discrete or confluent

,istribution ) ,uration,istribution ) ,uration

"he appearance associated with fever"he appearance associated with fever


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Key Questions:

/ 0cute or Chronic *ecurrent2/ When did it start/ Pattern of +pread

/ +ic3 or Well

/ Pruritic/ (edications/ 45posures


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Describe What You See

0. Pattern6,istributionDi%%"se or -ocali.ed

M"co"s Me!0ranes

#al!s 1 SolesE2posed vs3 Une2posed Areas

7. 8ndividual 'esions4olor

Si.eBlanches

4haracerisics

C. 9ther Physical $indings


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Primary Lesions

(acule : $lat) cannot be palpated

Papule : Palpable solid lesions 1cm

;odule : Palpable solid lesions .&cm

7ulla : 'arger vesicle

Pustule : Purulent vesiclePla?ues: 0ggregations of any of the above

primary lesions


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Secondary Lesions(Resulting from infection, trauma, or therapy

+cales

@lcers

45coriations

$issuresCrusts

+cars


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TABLE 1TABLE 1

!ommon Primary S"in Lesions!ommon Primary S"in Lesions

(acule : Circumscribed area of change in normal s3in color) with no s3in(acule : Circumscribed area of change in normal s3in color) with no s3in

elevation or depressionA may be any sieelevation or depressionA may be any sie

Papule : +olid) raised lesion up to >.& cm in greatest diameterPapule : +olid) raised lesion up to >.& cm in greatest diameter

;odule : +imilar to papule but located deeper in the dermis or;odule : +imilar to papule but located deeper in the dermis or

subcutaneous tissueA differentiated from papule by palpabilitysubcutaneous tissueA differentiated from papule by palpability and depth) rather than sieand depth) rather than sie

Pla?ue : 4levation of s3in occupying a relatively large area in relation toPla?ue : 4levation of s3in occupying a relatively large area in relation to

heightA often formed by confluence of papulesheightA often formed by confluence of papules

=esicle : Circumscribed) elevated) fluid-containing lesion less than >.& cm in=esicle : Circumscribed) elevated) fluid-containing lesion less than >.& cm in

greatest diameterA may be intraepidermal or subepidermal in origingreatest diameterA may be intraepidermal or subepidermal in origin

7ulla :+ame as vesicle) e5cept lesion is more than >.& cm in diameter7ulla :+ame as vesicle) e5cept lesion is more than >.& cm in diameter

Pustule : Circumscribed elevation of s3in containing purulent fluid of variablePustule : Circumscribed elevation of s3in containing purulent fluid of variable

character i.e.) fluid may be white) yellow) greenish or hemorrhagic2character i.e.) fluid may be white) yellow) greenish or hemorrhagic2


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M5RBI--IM5RBI--I

'Measles6 R"0eola)'Measles6 R"0eola)0cute infection) contagious) caused by morbilli0cute infection) contagious) caused by morbilli

=irus $amili Paramy5oviridae2=irus $amili Paramy5oviridae2# stadia : Prodromal# stadia : Prodromal

4rupstion4rupstion

ConvalescensConvalescens4ndemic in developing countries4ndemic in developing countries

4ffective imuniation program4ffective imuniation programcases decreasingcases decreasing

prone to older age groupprone to older age group


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#aholo&y#aholo&y

'esion particularly at :'esion particularly at :

- +3in- +3in

- (ucous membranes :- (ucous membranes :respiratory : nasopharyng) bronchirespiratory : nasopharyng) bronchi

digestive : oral cavity) intestinedigestive : oral cavity) intestine

- ConBungtiva- ConBungtiva

+erous e5udate)+erous e5udate)

mononuclear cell predominantmononuclear cell predominant


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4linical !ani%esaions4linical !ani%esaions

8ncubation period : 1> 1 days8ncubation period : 1> 1 days+tadium+tadium prodro!al +prodro!al +

-- 44orya)orya) 44ough)ough) 44onBungtivitisonBungtivitis

- DKopli3 spotsE- DKopli3 spotsE

--

FeverFever

+tadium+tadium er"pion +er"pion +

- igh fever : %> %>)&- igh fever : %> %>)&>>CC

-- "ypical rash: maculopapular eritromatosus"ypical rash: maculopapular eritromatosus

eadead truncustruncus e5tremitiese5tremities+tadium+tadium convalescens+convalescens+

- rash : hyperpigmentation macule6s?uama- rash : hyperpigmentation macule6s?uama

- sign and symptoms resolve- sign and symptoms resolve


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Dia&nosisDia&nosis

0namnesis :0namnesis :- symptoms- symptoms

- history : - contact- history : - contact

- imuniation- imuniation

Clinical signs: typicalClinical signs: typical

'aboratorium :'aboratorium :

- leu3openia)- leu3openia)

- relative lymphocytosis- relative lymphocytosis


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4o!plicaion4o!plicaion

Pneumonia 6 7ronchopneumonia A 9titis mediaPneumonia 6 7ronchopneumonia A 9titis media C;+ : - meningoensefalitisC;+ : - meningoensefalitis

- +ubacute +clerosing Pan 4ncephalitis- +ubacute +clerosing Pan 4ncephalitis

Persisten diarrheaPersisten diarrhea

protein lossing enteropathyprotein lossing enteropathy

45aserbation of "7C45aserbation of "7C

KeratoconBunctivitisKeratoconBunctivitis blindnessblindness

+econdary bacterial infection of s3in+econdary bacterial infection of s3in (yocarditis(yocarditis

;oma;oma


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#ro&nosis#ro&nosis

Particularly good prognosisParticularly good prognosis

C$* decreasedC$* decreased

(ortality caused by complication(ortality caused by complication


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Trea!enTrea!en

+y+ymptomaticmptomatic

+upportive+upportive

=itamin 0 :=itamin 0 :

@nicef6W9 reccomendation@nicef6W9 reccomendation

(anagement of complication(anagement of complication


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#revenion#revenion

0ctive immuniation:0ctive immuniation: - (easles vaccine- (easles vaccine

- when F months old- when F months old

- booster: 1& months --< ((*- booster: 1& months --< ((*

Passive immuniationPassive immuniation


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RUBE--A '7er!an Measles)RUBE--A '7er!an Measles)

0cute infection) contagious) caused by rubela0cute infection) contagious) caused by rubela

virusvirusfamily "ogaviridae2family "ogaviridae2 prodromal sign : G 6 -prodromal sign : G 6 -

*ash : short periode*ash : short periode # days# days "ypical sign: lymphadenopathy"ypical sign: lymphadenopathy

post auricular suboccipital post auricular suboccipital

posterior colliposterior colli

Problems in pregnant womenProblems in pregnant women Congenital rubella SyndromeCongenital rubella Syndrome


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Congenital rubella SyndromeCongenital rubella Syndrome

,epend on gestational age,epend on gestational age

AbortusAbortus

StillbirthStillbirthCongenital anomalyCongenital anomaly

gravida 1 % wee3s : I1Jgravida 1 % wee3s : I1J & H wee3s : I J& H wee3s : I J

F 1 wee3s : HJF 1 wee3s : HJ


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Congenital rubella SyndromeCongenital rubella Syndrome

9pthalmologic : cataract (icropthalmia9pthalmologic : cataract (icropthalmia lau3oma - chorioretinitislau3oma - chorioretinitis

Cardiac : +eptal ,efect P,0Cardiac : +eptal ,efect P,0

;eurologic : (eningoencephalitis ;eurologic : (eningoencephalitis

(icrocephaly mental *etardation(icrocephaly mental *etardation

0uditoric : sensorineural deafness0uditoric : sensorineural deafness


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E2anhe! s"0i"!E2anhe! s"0i"!

' Roseola in%an"! )' Roseola in%an"! )

0cute infection caused by0cute infection caused by Human HerpesHuman Herpes Virus 6 ( some HHV 7 )Virus 6 ( some HHV 7 )

(ostly in infant(ostly in infant

+poradic sometimes epidemic2+poradic sometimes epidemic2

"ypical feature :"ypical feature :- +everity of clinical sign unproportionally with- +everity of clinical sign unproportionally with

degree of feverdegree of fever

- +imultaniously resolve of rash and clinical sign- +imultaniously resolve of rash and clinical sign


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4linical Mani%esaion4linical Mani%esaion

8ncubation period : L 1L days 8ncubation period : L 1L days GG1> days 21> days 2(ost common in I 1H months old(ost common in I 1H months old$ever$ever

- abruptly high A #F)% %1)- abruptly high A #F)% %1)>>CC

- ,uration: 1 & days mostly # % days 2- ,uration: 1 & days mostly # % days 2

- Convulsion can occur- Convulsion can occur(ild clinical sign :(ild clinical sign :

- mild pharyngitis and corya- mild pharyngitis and corya*ash : not specific*ash : not specific

macule 6 maculopapular A rose colour :macule 6 maculopapular A rose colour :chest < e5remities and nec3chest < e5remities and nec3 faceface

0ppear while temperature has return to normal0ppear while temperature has return to normal

,isappear on 1 days with normal s3in,isappear on 1 days with normal s3in


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#ro&nosis#ro&nosis

Particularly good prognosisParticularly good prognosis

7ad prognosis :7ad prognosis :

- hyperpyre5ia with persistent convulsion- hyperpyre5ia with persistent convulsion


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TreatmentTreatment

+ymptomatic+ymptomatic


#revenion + #revenion +


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#iral $%anthem#iral $%anthem

Summary &ableSummary &ableViral Syndrome Causative

Virus

Exanthem/Enanthem Age/Epidemiol

ogy

Associated Symptoms

Roseola ''#)(''#*

$rythematous macules an+papules surroun+e+ byhite halos-

.nfantPreschool 'igh fe/er % 0 +ays, then rash-1il+ 2R. s%-

!omplications: febrile s3-

$rythema .nfectiosum Par/o/irus 456 $rythematous7slappe+8 chee"s, folloe+by reticulate erythema onbo+y

Schoolage Logra+e fe/er

'an+9ootan+1outhDisease

!o%sac"ie 5),); $ntero/irus*5; others

ority of casesin 2S areimporte+-

Pro+rome: 9e/er, 1alaise,!on>uncti/itis, !ough, !ory3a.nfectious complications-

Rubella Rubella Pruritic pin" macules an+papules, sprea+ from hea++on o/er ?@ hrs-Petechial lesions on softpalate (9orsheimerAs sign

1a>ority are/accinate+-

9e/er, ', 2R. s%,con>uncti/itis,lympha+enopathy-!ongenital rubella syn+rome-


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S4AR-ET FE8ER 'S4AR-ATINA)S4AR-ET FE8ER 'S4AR-ATINA)

7r"p A 0ea,he!olyic Srepococc"s7r"p A 0ea,he!olyic Srepococc"spyrogenic to5in erytrogenic to5in2pyrogenic to5in erytrogenic to5in2

Clinical manifestation :Clinical manifestation :

- 8ncubation period : 1 L days mean : # days2- 8ncubation period : 1 L days mean : # days2

- 0cute symptoms:- 0cute symptoms:high fever headache vomiting- chillshigh fever headache vomiting- chills

- +igns: severe pharyngitis- +igns: severe pharyngitis

hyperemis edema e3sudate- dysphagiahyperemis edema e3sudate- dysphagia

- DCircum oral pallorE dan DPastia linesE- DCircum oral pallorE dan DPastia linesE - Dwhite strawbey tongueE- Dwhite strawbey tongueE des?uamationdes?uamation

DDred strawberry tongueEred strawberry tongueE


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Typical rash+Typical rash+

-*eddish macule 6 papule*eddish macule 6 papule blanching on pressureblanching on pressure

-$irstly on a5illa) groin and nec3$irstly on a5illa) groin and nec3

% hours all of body% hours all of body- +evere disease :+evere disease :miliaria sudaminamiliaria sudamina

- PetechiaePetechiaecan occurcan occur

- DesquamationDesquamationoccur from end of 1occur from end of 1ststwee3wee3

to Ito Iththwee3 of diseasewee3 of disease


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Dia&nosisDia&nosis

istory and physical e5aminationistory and physical e5amination

Pharyngeal swab : bacterial culturePharyngeal swab : bacterial culture

+erologic : 0+"96 0+'96 0+9+erologic : 0+"96 0+'96 0+9

Complete blood count : leu3ositosisComplete blood count : leu3ositosis C*P increased or G2 : not specificC*P increased or G2 : not specific


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4o!plicaion4o!plicaion

-ocal spread / per conin"ia"!+-ocal spread / per conin"ia"!+ - +inusitis 9titis media - (astoiditis- +inusitis 9titis media - (astoiditis

- *etro 6 para parapharyngeal absces- *etro 6 para parapharyngeal absces

- 7ronchopneumonia- 7ronchopneumonia

- +ervical adenitis- +ervical adenitis

9e!ao&enic spread9e!ao&enic spread::

- (eningitis 9steomyelitis- (eningitis 9steomyelitis

0rthritis septic20rthritis septic2

Non,s"pp"raive 'lae) co!plicaion+Non,s"pp"raive 'lae) co!plicaion+

- 0cute rhematic fever- 0cute rhematic fever

- 0cute lomerulonephritis- 0cute lomerulonephritis


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Trea!enTrea!en

0ntibiotics :0ntibiotics :

- Penicillin group- Penicillin group

- 0llergy to penicillin :- 0llergy to penicillin :

4rythromycin lincomycin 4rythromycin lincomycin

Clindamycin- Cephadro5ilClindamycin- Cephadro5il

+ymptomatic+ymptomatic


(anagement of Complication(anagement of Complication


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2 fever and rash

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