EXANTHEMOUS PYREXIA.

Dr Mohin M SakrePG cum TutorDept. Of Community MedicineKBNIMSEXANTHEMATOUS PYREXIA.

INDEXFever - Definition and broad causes.Rash(Exanthema) - Definition and causes(broadly).Classification of rash.Common history of rash. Details to be taken of the rash before diagnosis.Physical examination before diagnosis of a rash.Clinical classification of rash.Centrally distributed v/s peripheral rash.Differential diagnosis of fever with rash.

FEVER.An elevation of body's temperature above the normal range of 36.5-37.5(97.7-99.5 degree Fahrenheit) degree Celsius due to an increase in the hypothalamic set point( Harrison).

Cause:Physiologically classified broadly under:Pyogens: Microbial products, Microbial toxins, or whole micro organisms.Pyogenic cytokines: Produced during infection and inflammatory process - IL6, IL1, TNF, Ciliary neurotropic factor and Interferon.

Cause:Neoplasm: Hypernephroma, lymphoproliferative malignancies, carcinoma of pancreas, lung and bone and hepatoma may cause fever.Vascular Causes: Acute myocardial infarction, pulmonary embolism. Pontine hemorrhage may also cause fever.Trauma: A massive crush injury may lead to pyrexia.

RASH.

Is a change of the skin which affects its colour, appearance or texture. It may occur due to:(Broadly, Physiologically:)Multiplication of the infective organism in the skin.Toxins produced by the microbes that act on the skin.Auto immune destruction of the skin due to inflammatory responses to foreign particles.Involvement of the vasculature. E.g.: Vasoocclusion, Necrosis and vasodilatation.

STRUCTURAL CLASSIFICATION OF RASH.

MACULENODULEPLAQUEPAPULE

STRUCTURAL CLASSIFICATION OF RASH.

PUSTULEVESICLEBULLAPALPABLE RASHNON PALPABLE RASH

DETAILS TO BE TAKEN BEFORE THE DIAGNOSIS OF RASH.

CLINICAL CLASSIFICATION OF RASH.

Maculopapular eruptions.Confluent desquamative erythema.Vesiculobullous or pustular eruptions.Utricaria like eruptions.

CLINICAL CLASSIFICATION OF RASH.

Nodular Eruptions.Purpuric EruptionsEruptions with ulcers or eschars.

CENTRALLY DISTRIBUTED RASH.

PERIPHERALLY DISTRIBUTED RASH.

DIFFERENTIAL DIAGNOSIS OF EXANTHEMATOUS FEVER

LESIONDESCRIPTIONPATHOGENS OR INFECTIONMaculopapular rash1) Macules: Red/Pink discrete flat areas that blanch on pressure.2) Papules: Solid, raised hemispherical lesions that are tiny and blanch on pressure.1) Viral: Measles, Rubella, Erythema infectiosum, EBV, HBV, HIV.2) Bacterial: Erythema marginatum, Scarlet fever, Erysipelas, 2nd syphilis, leptospirosis.3) Risketessial: Typhus and rocky mountain spotted fever.4) Others: RA, Kawasakis disease, Drug reaction.Diffuse ErythrodermaThickened scaly skin on palms and soles1) Bacterial: Scarlet fever, toxic shock syndrome, staphylococcal infection.2) Fungi: Candida albicans.3) Others: Kawasakis synd.

DIFFERENTIAL DIAGNOSIS OF EXANTHEMATOUS FEVERLESIONDESCRIPTIONPATHOGENS OR INFECTIONSUtricarial rashSwelling of the lesions that appear and resolve rapidly1)Viral: EBV, Hep B, HIV.2) Bacterial: M. Pneumoniae and group A streptococcus.3) Others: Drug reaction.Vesicular, Pustular and Bullous1) Vesicular: Raised, hemi spherical lesions containing clear fluid and less than 0.5 cm.2) Pustular, Bullous: Raised hemi spherical lesion that is greater than 0.5 cm containing clear or purulent fever.1) Viral: HSV, VZV, Cox Sackie virus.2) Bacterial: Staphylococcus aureus, Bullous impetigo, Streptococcus crusted impetigo.3) Others: Toxic epidermal necrosis, Steven Johnson syndrome.4) Ricketessial pox.

DIFFERENTIAL DIAGNOSIS OF EXANTHEMATOUS FEVERLESIONDESCRIPTIONPATHOGENS OR INFECTIONPetechial, PurpuricNon blanching purple or red spots.1) Viral: Atypical measles, Congenital rubella, CMV, Entero virus, HIV.2) Bacterial: Meningococcal, Streptococcal and Gonococcal sepsis.3) Ricketessial: Rocky mountain spotted fever.4) Fungi: Aspergillus Mucor.5) Others: Vasculitis, Thrombocytopenia, Hench Schonlen purpura and malaria.

DIFFERENTIAL DIAGNOSIS OF EXANTHEMATOUS FEVERLESIONDESCRIPTIONPATHOGENS OR INFECTIONErythema NodosumTender, red nodules that occur due to exudation of blood and serum1) Viral: EBV, HBV.2) Bacterial: Group A streptococcus, TB, Yesrinia, Cat scratch disease.3) Fungi: Coccidiomycosis and histoplasmosis.4) Others: Sarcoidosis, OCP, SLE.

MEASLES

INDEX OF MEASLES

Characteristics of Measles.Epidemiology.Problem statement.Clinical manifestations.Other manifestations.Investigations.Diagnosis.

INDEX OF MEASLESComplications.Treatment.Prevention: Measles surveillance.Measles Vaccine.Measles Post exposure Prophylaxis.Isolation. Prognosis.Global goal of Measles control.India's role in the global goal of measles control.WHO Measles and Rubella eradication plan.

Etiology and Characteristics.CharacteristicsExplanationCausative agentMeasles Virus(ssRNA Paramyxo virus)HostManInvadesUpper respiratory tract and regional lymph nodesTransmitted byLarge respiratory drops with no fomites(Close contact transmission). Human to HumanVirus present inRespiratory secretions, blood and urine.Period of communicabilityContagious from 5 days before to 4 days after the appearance of rash.AgeInfancy or 6 months to 3 years of age. In developed countries, in children above 5 years of age.NutritionVery severe in mal nourished children.Environmental factorsIn poor setups

EPIDEMIOLOGY

PROBLEM STATEMENT

CLNICAL MANIFESTATIONS

STIMSON LINEKOPLIKS SPOTCHARACTERISTIC RASH IN MEASLES

Other sever manifestations of Measles:

INVESTIGATIONSSerological tests:IgM antibody: Appears in 1-2 days of rash.Persists for 1-2 months.Chest X ray:Interstitial infestations.Negative measle pneumoniae vs. bacterial super Infection.

Diagnosis:Clinical.Serology.Viral culture.PCR.

COMPLICATIONS

Interstitial pneumonia(50-75%).

Acute Otitis media(10 - 15%).

Myocarditis and pericarditis.

Encephalitis(1/1000cases) 7 to 10 days after rash.

Subacute sclerosis panencephalitis( Less common and Very fatal ).

Mesenteric lymphadenitis.

TREATMENT

PREVENTION

Measles surveillance.

Measles vaccine.

Measles Post exposure Prophylaxis.

Isolation of cases till 7 days after onset of rash.

MEASLES SURVEILLANCE

Measles Vaccine.

Live attenuated.

Freeze dried vaccine.

Lyophilised.

Human diploid cell vaccine.

Edmonston Zagreb strain.

Heat sensitive - Stored frozen at 2-8 degree Celsius.

The reconstituted vaccine is kept on Ice before administration( for 4 hours ) and beyond that discarded.

Indian national immunisation schedule: Single dose at 9 months(Also WHO EPI)

Indian academy of paediatrics: One dose of measles at 9 months and one dose of MMR at 15 months.

Can be given between 6 to 9 months of age if;1) Measles outbreak has occurred in the community.2) To malnourished children with a high risk of complications.

The second dose needs to be given after 4 weeks.Given in the form of 0.5ml sub cutaneous injection. The usual site is the right upper arm.

INDICATIONS, PRECAUTIONS AND CONTRAINDICATIONSMild illnesses are not a contraindication to vaccination.

Vaccination should be avoided if the patient is having high fever or having serious disease or if the patient is immunocompromised in any way.

Measles vaccine can be given to adolescent and adults if susceptible or travelling to endemic areas but should be avoided during pregnancy.

Early stages of HIV infection is not a contraindication to measles immunization.

People with a history of an anaphylactic reaction to components of the vaccine should not be vaccinated.

ADVERSE EFFECTS OF MEASLES VACCINE.Pain and tenderness at the site of injection.

Fever(5%), occasionally with seizures(1:3000).

Transient rash(2%).

Thrombocytopenic purpura(1:30000).

Anaphylactic reactions(1:100000).

Measles Vaccines, Effectiveness and Duration of Protection

Live, attenuated measles vaccines are available, either as monovalent vaccine or as measles-containing vaccine (MCV) in combination with rubella or mumps vaccines.

Following vaccination, the long-term persistence of neutralizing measles antibodies (up to 33 years) and long-lasting protection against measles have been demonstrated.

MEASLES POST EXPOSURE PROPHYLAXIS

Measles Isolation and prognosis.

ISOLATION - Infected people should be isolated for four days after they develop a rash. Healthcare providers should follow respiratory etiquette and airborne precautions in healthcare settings. Regardless of presumptive immunity status,

PROGNOSIS - Measles usually clears up about 7 to 10 days from the appearance of rash. Once exposed the person is immune for life. The complications, however rare are severe and fatal. Hence, the need to appropriate and adequate vaccination.

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Global Goal for Measles ControlThe key strategies being followed globally for measles mortality reduction are:High coverage of Measles 1stdose: Coverage for 1stdose measles vaccine must be90% at national level and 80% for each district in routine immunization.Sensitive laboratory supported surveillance:Outbreak andcase based surveillance fully supported by laboratories for serological and virological classification. Appropriate measles case management:Including administration of vitamin A to reduce mortality and complications.Providing 2nddose of measles vaccine: By single dose RI and SIA(Supplementary immunization activity).

NTAGI Recommendations for India.In accordance to the Global goal for measles control, the NTAGI recommended:A second dose of measles vaccine should be introduced in the IP at the time of DPT booster dose (at 16-24 months of age) in states with80% evaluated coverage with the first dose of measles vaccine.Catch-up measles vaccination campaigns should be implemented for children aged 9 months to 10 years in states with