Fever with rash by Dr.Eugene


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Fever with rash by Dr.Eugene

  1. 1. Fever with Rash Fever With Rash Chooi Yuo Hao (Eugene) 1
  2. 2. •Varicella Zoster Virus (VZV) • Perinatally acquired varicella•Kawasaki Disease Fever With Rash 2
  3. 3. History Taking• Introduction• Chief complaints• HOPI• Past history (Medical and Surgical)• Birth history Fever With Rash• Feeding history• Developmental history• Immunization history• Drug history• Family history 3• Social and environmental history
  4. 4. Physical examination• General examination• Systemic examination Fever With Rash 4
  5. 5. Varicella Zoster Virus (VZV)• 1 of the known human herpes viruses • Varicella Zoster Virus (VZV) – Chicken Pox • Herpes Zoster – Shingles• Neurotropic human herpes virus with similarities to Fever With Rash herpes simplex virus• Air-borne and highly contagious disease• Causes primary, latent and recurrent infections• Increased morbidity and mortality in adolescent, adults, and immunocompromised persons 5• Predisposed to severe group A streptococcus and Staphylococcus aureus infection
  6. 6. Clinical Manifestation• Prodromal symptoms • Nausea, loss of appetite, aching muscle and headache• Fever (mostly low grade), malaise, 24-48hrs later associated with vesicular rash (successive crops of pruritic vesicles that evolve to pustules, crusts and Fever With Rash at times scar4)• Rashes starts from the scalp, face or trunk, upper extremities and lower extremities• Some children might not have prodromal symptoms, they begins with vesicular rash and fever 6
  7. 7. Fever With Rash 7Varicella lesion
  8. 8. Fever With Rash 8Vesicular rash of chicken pox
  9. 9. Fever With Rash 9Haemorrhagic chickenpox
  10. 10. Complications• Bacterial superinfection • Staphylococcal • Streptococcal • May lead to toxic shock syndrome or necrotizing fasciitis• Central nervous system Fever With Rash • Generalized encephalitis • Aseptic meningitis• Immunocompromised • Haemorrhagic lesions • Pneumonitis • Progressive and disseminated infection 10 • Disseminated intravascular coagulation
  11. 11. Treatment• Antiviral treatment – Acyclovir• Human varicella zoster immunoglobulin (ZIG) is recommended for high-risk immunosuppressed individuals Fever With Rash 11
  12. 12. Prognosis• Quite good excluded immunosuppressed patients• Resolves spontaneously – self limited• Mortality rate 2-3 per 100,000 cases Fever With Rash 12
  13. 13. Prevention• Difficult to prevent as the infection is highly contagious for 24-48 hour before the rash appears.• Live attenuated VZV vaccine can be administer• Postexposure prophylaxis – VZV vaccine or oral Fever With Rash acyclovir Beware of admitting a chickenpox contact to a clinical area with immunocompromised children 13
  14. 14. Perinatally Acquired Varicella• Maternal infection (onset of rash) within 5 days before and 2 days after delivery• Mortality rate is high, due to severe pulmonary disease or widespread necrotic lesions of viscera Fever With Rash• The production and transplacental passage of maternal antibodies that modify the course of illness in new-borns• Exposed susceptible women can be protected with varicella zoster immune globulin (VZIG) and treated with acyclovir. 14
  15. 15. • Women with varicella lesions should be isolated from their newborns, breast feeding is contraindicated; when all the lesions have crusted, breast feeding should be commence• Neonates with varicella lesions should be isolated Fever With Rash from other infants but not from their mothers.• Infants born in the high-risk period should also receive zoster immune globulin and are often also given acyclovir prophylactically 15
  16. 16. Summary• Primary, latent and recurrent infections• Primary infection is manifested as varicella – chickenpox• Results in establishment of a lifelong latent infection of sensory ganglion neurons• Reactivation of the latent infection causes herpes zoster – shingles Fever With Rash• Increase morbidity and mortality in adolescents, adults and immunocompromised persons, and predisposes to severe group A streptococcus and Staphylococcus aureus infections• Can be treated with antiviral drugs• Initial infection can be prevented by immunization with live- attenuated VZV vaccine 16
  17. 17. Kawasaki Disease• Also known as acute febrile mucocutaneous syndrome• A systemic febrile condition affecting children usually <5 years old• Aetiology remains unknown, possible bacterial Fever With Rash toxins or viral agents with genetic predisposition• Aneurysms of the coronary arteries are an important complication• Affects children 6 months – 4 years old, with a peak at the end of the first year 17
  18. 18. Diagnostic criteria• Exclusive diagnosis• Fever (HGF, remittent and unresponsive to antibitics) lasting at least 5 days• At least 4 out of 5 of the following • Bilateral non-purulent conjunctivitis Fever With Rash • Mucosal changes of the oropharynx (injected pharynx, red lips, dry fissured lips, strawberry tongue) • Change in extremities (oedema and/or erythema of the hands or feet desquamation, beginning periungually) • Rash (usually truncal), polymorphous but not vesicular • Cervical lymphadenopathy 18• Illness not explained by other disease process
  19. 19. Fever With Rash 19Red, cracked lips and conjunctiva inflammation
  20. 20. Fever With RashCongestion of bulbar conjunctiva 20
  21. 21. Fever With Rash 21Strawberry tongue
  22. 22. Fever With Rash 22Peeling of fingers
  23. 23. Fever With RashDesquamation of the fingers 23
  24. 24. Fever With RashIndurative edema 24
  25. 25. Other helpful signs • Indurated BCG scar • Perianal excoriation, irritability • Altered mental state • Aseptic meningitis Fever With Rash • Transient arthritis • Diarrhoea, vomiting, abdominal pain • Hepatoslenomegaly • Hydrops of gallbladder • Sterile pyuria 25
  26. 26. Investigation• Full blood count • Anaemia, leukocytosis, thrombocytosis• ESR and CRP elevated• Serum albumin <3gdl; Raised alanine Fever With Rash aminotrasaminase (ALT)• Urine > 10 wbc/hpf• Chest x-ray, ECG• Echocardiogram in the acute phase and repeat at 6-8 weeks or earlier if indicated 26
  27. 27. Fever With RashCoronary angiogram demonstrating giant aneurysms of theLAD with obstruction and giant aneurysms of the RCA with 27 area of severe narrowing
  28. 28. Complication• Coronary vasculitis, usually within 2 weeks of illness• Asymptomatic • Myocardial infection • Fever With Rash Myocardial infarction • Pericarditis • Myocarditis • Endocarditis • Heart failure • Arrhythmias 28
  29. 29. • Incomplete Kawasaki Disease (kindly refer to the 2nd edition of paeds protocol pg 115)• Atypical Kawasaki Disease (kindly refer to the 2nd Fever With Rash edition of paeds protocol pg 115) 29
  30. 30. Fever With Rash 30Evaluation of Suspected Incomplete Kawasaki Disease
  31. 31. Treatment• Primary treatment • IV Immunoglobulins 2 Gm/kg infusion over 10-12 hours Therapy <10 days of onset effective in preventing Fever With Rash coronary vascular damage • Oral Aspirin 30 mg/kg/day for 2 weeks or until patient is afebrile for 2-3 days 31
  32. 32. Maintenance• Oral Aspirin 3-5 mg/kg daily (anti-platelet dose) for 6-8 weeks or until ESR and platelet count normal If coronary aneurysm present, then continue aspirin Fever With Rash until resolves Alternative: Oral Dipyridamole 3-5mg/kg daily 32
  33. 33. Prognosis• Complete recovery in children without coronary artery involvement• Most (80%) 3-5mm aneurysm resolve • 30% of 5-8mm aneurysm resolve• Prognosis worst for aneurysms > 8mm; mortality Fever With Rash 1~2%• Good prognosis for aneurysms <4mm 33
  34. 34. Summary• Mainly affects infants and young children• The diagnosis is made on clinical features such as• Fever lasting at least 5 days• At least 4 out of 5 of the following • Bilateral non-purulent conjunctivitis Fever With Rash • Mucosal changes of the oropharynx (injected pharynx, red lips, dry fissured lips, strawberry tongue) • Change in extremities (oedema and/or erythema of the hands or feet desquamation, beginning periungually) • Rash (usually truncal), polymorphous but not vesicular • Cervical lymphadenopathy• Complications – Coronary artery aneurysms and 34 sudden death• Treatment – Intravenous immunoglobulin and aspirin
  35. 35. References• Hussein Imam, Ng H.P., Thomas T. (2008). Paediatrics Protocols for Malaysian Hospitals (2nd edition): pg 6,78,115- 116• Lissauer T., Clayden G. (2007). Illustrated textbook of Paediatrics (3rd edition): pg 230-232, 237-238 Fever With Rash• Kliegman R.M., Beherman R.E., Jenson H.B., Stanton B.F. (2007). Nelson textbook of Paediatrics (18th edition)• Klaus W., Richard A.J. (2009). Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology (6th edition): pg 833• Kliegman R.M., Marcdante K.J., Beherman R.E., Jenson H.B. (2007). Nelson Essentials of Paediatrics (5th edition): pg 470- 472 35
  36. 36. Fever With Rash36