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Fever with Rash
- 2. Fever ‐an elevation of body temperature above the normal range of 36.5–37.5 °C (97.7–99.5 °F) due to an increase in the hypothalamic set point .(Harisson) Cause‐ 1. Pyrogens ‐ microbial products, microbial toxins(endotoxin), or whole microorganisms 2. Pyrogenic Cytokines produced during infection and inflammatory procces ‐ IL‐1, IL‐6, tumor necrosis factor (TNF), ciliary neurotropic factor (CNTF), and interferon (IFN) Dr N Anand ANAND
- 3. Rash is a change of the skin which affects its color, appearance, or texture. It may occur due to 1. Multiplication of infective organism in the skin(e.g.,HSV) 2. Toxin produced by organisms acting on skin structures 3. Autoimmune destruction of Skin due to inflammatory response against the infecting microbes 4. Involvement of the vasculature‐ Vasoocclusion,Necrosis,Vasodilatation Dr N Anand ANAND
- 4. Macule Circumscribed area of change in normal skin color, with no skin elevation or depression; may be any size Papule Solid, raised lesion up to 0.5 cm in greatest diameter Nodule Similar to papule but located deeper in the dermis or subcutaneous tissue; differentiated from papule by palpability and depth, rather than size Classification of Rash Dr N Anand ANAND
- 5. Macule Patch Dr N Anand ANAND
- 6. Papule Plaque Dr N Anand ANAND
- 7. Plaque Elevation of skin occupying a relatively large area in relation to height; often formed by confluence of papules Vesicle Circumscribed, elevated, fluid‐containing lesion less than 0.5 cm in greatest diameter; may be intraepidermal or subepidermal in origin Pustule Circumscribed elevation of skin containing purulent fluid of variable character (i.e., fluid may be white, yellow, greenish or hemorrhagic) Dr N Anand ANAND
- 8. Bulla Same as vesicle, except lesion is more than 0.5 cm in greatest diameter Nonpalpable Purpura Flat red lesion due to bleeding in to the skin Palpable Purpura Raised red lesion due to inflammation of the vessel wall Dr N Anand ANAND
- 9. Vesicle Pustule Bulla Dr N Anand ANAND
- 11. 6. Sexually transmitted disease exposure, including risk factors for infection with human immunodeficiency virus (HIV) 7. Exposure to febrile or ill persons within the recent past 8. Exposure to wild or rural habitats, insects, arthropods, and wild animals 9. Exposure to outdoor water sources such as lakes, streams, or oceans 10. Pets, animal exposures, and habits Dr N Anand ANAND
- 16. Classification of Rash • Maculopapular Eruptions • Confluent Desquamative Erythemas • Vesiculobullous or Pustular Eruptions • Urticaria like eruptions • Nodular Eruptions • Purpuric Eruptions • Eruptions with Ulcers or Eschars Dr N Anand ANAND
- 19. 3) Bacterial Epidemic Typhus Endemic Typhus Scrub Typhus Rheumatic Fever Leptospirosis Lyme Disease Relapsing Fever Typhoid Fever Rickettsial Spotted Fevers Rat‐bite Fever(soduku) Human Monocytotropic Ehrlichiosis African Trypanosomiasis 4) Autoimmune Systemic Lupus Erythematosus Still’s Disease Dr N Anand ANAND
- 21. MEASLES(Rubeolla,First Disease) Causative Agent Measles Virus(Paramyxovirus) Host Common in Chidren and Nonimmune Mode of Spread Droplet Infection Incubation Period 10 Days Rash Macular‐popular rash that may become confluent; begins on face(at the hairline), neck and shoulders and spreads centrifugally and inferiorly; fades in 4 to 6 days CLINICAL FEATURES High grade fever with cough, coryza, conjunctivitis,malaise,irritability Koplik spots (buccal mucosa)appears 2 days prior to rash Dr N Anand ANAND
- 22. Complications Acute otitis media Interstitial pneumonia Myocarditis and pericarditis Encephalitis Subacute sclerosis panencephalitis(SSPE) Mesenteric lymphadenitis Diagnosis Clinical examination IgM antibody detection Viral RNA Detection by RT‐PCR Treatment Supportive Adequate Hydration Dr N Anand ANAND
- 23. Measles RashKoplik’s Spot Dr N Anand ANAND
- 24. RUBELLA(German Measles,Third Disease) Causative Agent Rubella virus ( ssRNA, togavirus family) Host Young adults,nonimmune persons Mode of Spread Droplet Infection Incubation Period 18 Days Rash Pink macules and papules develop on forehead spread to extremities, fades by third day Forchheimer's sign (20% of cases)‐ small, red papules on the area of the soft palate Dr N Anand ANAND
- 25. CLINICAL FEATURES Low grade fever Maculopapular Rash Sub occipital & Posterior cervical lymphadenopathy Joint pains Headache and conjunctivitis Congenital rubella syndrome due to transplacental transmission to fetus ‐ • Sensorineural deafness • Congenital Heart Diseases ‐ Pulmonary artery stenosis and Patent ductus arteriosus • Ophthalmic Diseases‐Retinopathy, Cataract, and Microphthalmia Dr N Anand ANAND
- 26. Diagnosis Rise in specific IgG antibodies Treatment No specific therapy Routine supportive care Prevention Live attenuated MMR vaccine Children at age 12‐15 months of life Children at age 4‐6 yrs old Women of Child Bearing Age Dr N Anand ANAND
- 28. ERYTHEMA INFECTIOSUM (Fifth disease) Causative Agent Human Parvovirus B19 Spreads by Respiratory Secretions Host and Environment Children 3 to 12 years of age Occurs in Winter and Spring Rash Classic Bright‐red facial rash(“slapped cheek“) and progresses to lacy reticular rash; may wax and wane for 6 to 8 weeks Clinical Features Mild Fever Arthritis in Adults Rash after fever resolves Diagnosis Serology –B19V IgM Antibodies Detection Treatment Supportive Dr N Anand ANAND
- 29. Complications due B19 virus • Polarthropathy Syndrome • Transient Aplastic Crisis • Pure red‐cell aplasia/Chronic Anemia in immunosuprresed. • Hydrops fetalis in pregnant women Dr N Anand ANAND
- 30. ROSEOLA (Exanthem Subitum,Sixth Disease) Causative Agent Human Herpes Virus 6 Host and Environment Children under 3 years Rash Diffuse Macculopapular eruptions over trunk and neck resolves within 2 days Clinical Features High Fever lasting 3‐4 days Rash after fever resolves Febrile Seizures may occur Diagnosis Clinical findings Serology Treatment Supportive Dr N Anand ANAND
- 31. INFECTIOUS MONONUCLEOSIS Causative Agent Epstein‐Barr virus Host and Environment Young Adults (transmitted by intimate contact with bodily secretions) Rash Diffuse Maculopapular Eruption (5%) mainly due to ampicillin Urticaria ,Palatal petechiae Clinical Features Mostly Asymptomatic Fatigue and Malaise Fever, Pharyngitis, Cervical Lymphadenopathy Atypical lymphocytosis, Hepatosplenomegaly Diagnosis Peripheral Blood Lymphocytosis with atypical lymphocytes (>20 %) Elevated Liver Enzymes Heterophile antibody tests –Positive monospot Tests/Positive Paul Bunnell tests Treatment No Specific Treatment Steroids are indicated for severe complications Dr N Anand ANAND
- 33. Complications(rare) Neurological‐meningitis, encephalitis, hemiplegia, Guillain‐ Barré syndrome, and Transverse myelitis Hemolytic anemia and Thrombocytopenia Upper airway obstruction from tonsillar hypertrophy Myocarditis and pericarditis Chronic fatigue syndrome Cancers Hepatitis Splenic rupture Dr N Anand ANAND
- 34. Swollen Lymph Nodes Exudative Pharyngitis Dr N Anand ANAND
- 35. PRIMARY HIV INFECTION Host Individuals recently infected with HIV Clinical Features Fever Persistent Generalized lymphadenopathy Skin Rash Phayngitis Myalgia and Arthralgia Gastrointestinal symptoms Neurological symptoms‐GBS,Peripheral Neuropathy Rash 1‐2 Days of acute illness Nonspecific diffuse macules and papules commonly Urticarial or vesicular oral or genital ulcers may occur Desquamtion of palms and soles Diagnosis p24 antigen detection HIV RNA detection Dr N Anand ANAND
- 37. EPIDEMIC TYPHUS Causative Agent Ricketssia prowazekii Host and Environment Regions Affected by War and Disaster Vector Human Body Louse Incubation Period 1‐2 weeks Clinical Features Severe headache Sustained high fever Prominent Cough Maculopapular Rash Photophobia Myalgias Confusion and Coma 10‐40% Mortality if Untreated Dr N Anand ANAND
- 38. Rash Maculopapular rash appears in axillae,spreading to trunk and later to extremeties Spares Face,Palms,Soles Macules to Confluent eruptions with petechiae Complications Skin Necrosis and Gangrene Interstitial Pneumonia Diagnosis Serology Detection of R.Prowazekii in a louse on a patient Cross Adsorption Indirect Fluorescent Antibody Test Treament Doxycycline 100 mg BD continues 2‐3 days after defervescence Dr N Anand ANAND
- 39. ENDEMIC TYPHUS(Murine) Causative Agent Rickettsia typhi Host and Environment Exposure to Cat or Rat Fleas contaminated Feces Vector Rat Fleas Incubaton Period 8‐16 days Clinical Features Headache Myalgia Arthralgia Nausea and Vomiting Maculopapular Rashes(13 %) sparing Palms and Soles Pulmonary manifestations‐Interstitial pneumonia,Pulmonary Edema,Pleural Effusion Diagnosis Serology Treatment Doxycycline 100mg bd Ciprofloxacin Dr N Anand ANAND
- 40. SCRUB TYPHUS Causative Agent Orientia tsutsugamushi Host and Environment Heavy Scrub Vegetation During Wet Seasons Vector Trombiculid Mites Incubaton Period 6‐21 days Clinical Features Fever Rash Headache Myalgia Regional lymphadenopathy Cough Gastrointestinal symptoms Dr N Anand ANAND
- 41. Rash Diffuse Macular Rash Starting on the trunk Eschar at the site of Mite Bite Complications Pneumonitis Encephalitis Myocarditis Mortality up to 30% if untreated Diagnosis Eschar is diagnostic Weil‐Felix test Indirect immunofluorescence Treament Doxycycline 100mg bd oral 7‐15 days Azithromycin500 mg od oral 3 days Chloramphenicol 500mg qid oraln7‐15 days Dr N Anand ANAND
- 42. ESCHAR TYPHUS RASH Dr N Anand ANAND
- 43. ROCKY MOUNTAIN SPOTTED FEVER Causative Agent Ricketssia rickettsii Host and Environment Young adults with tick exposure Vector Tick Incubaton Period 2‐14 days Rash Rash evolving from pink macules to red papules and finally to petechiae(spotted) Rash beginning on wrists and ankles and Spreading centripetally Involvement of palms and soles late in disease Dr N Anand ANAND
- 44. Clinical Features Fever,Headache,Myalgia Nausea,Vomiting and Anorexia Rash begins peripherally and then spreads centrally Edema of the hands and feet is common Conjunctival suffusion and periorbital edema Cardiac involvement Meningoencephalitis Respiratory Faliure Diagnosis Thrombocytopenia with normal WBC and petechial rash Weil Felix Test Indirect immunofluorescence assay (IFA) Treatment Doxycycline 100 mg BD continued 2‐3 days after defervescence Dr N Anand ANAND
- 45. DENGUE FEVER Cause Dengue Virus Vector Female Aedes mosquitoes Clinical Features Febrile Phase Sudden Onset Fever Vomiting and Diarrhea Myalgia Gum Bleeding and Epistaxis Maculopapular Rash Critical Phase Hypotension and Shock Pleural Effusion andAscitis Bleeding‐GI Organ Impairment Metabolic Acidosis Recovery Phase Pruritis Bradycardia Dr N Anand ANAND
- 46. Rash Diffuse flushing Maculopapular rash begins on trunk and spreads to extremities and face; Petechiae on extremities Pruritus during recovery Severe Dengue 1. Plasma Leakage that may lead to shock 2. Severe Bleeding 3. Severe Organ Impairment Diagnosis Virus detection‐RTPCR NS 1 antigen detection Serology Treatment Supportive Adequate Hydration Blood Transfusion Management of Complications Dr N Anand ANAND
- 48. TYPHOID FEVER Causative Agent Salmonella typhi Mode of Transmission Ingestion of Contaminated food or Water Incubation Period 10‐14 days Clinical Features Prolonged High Fever up to 4weeks Relative Bradycardia Rash appears on first week Arthralgia and Myalgia GI symptoms‐Anorexia,Constipation,Diarrhoea Splenomegaly Hepatitis Rash Rose Spots seen on chest and abdomen in 1st week Small pale red Macules blanchable Lasts 2‐3 Days Dr N Anand ANAND
- 49. Complications GI Bleeding and perforation Meningitis,GBS,Peripheral Neuritis,Delirium Circulatory Collapse,DIC Chronic Carrier Osteomyelitis,Endocarditis,Pyelonephritis,Glomerulonephritis Hepatic and Splenic Abscess Diagnosis Leucopenia Raised Liver Enzymes Blood Cultures Widal Test Typhi Dot IgM PCR Treatment Supportive Care Antibiotics‐Ceftriaxone,Azithromycin,Cefixime Dr N Anand ANAND
- 51. LEPTOSPIROSIS Cause Leptospira interrogans Incubation Period 7‐14 Days Host Exposure to water contaminated with animal urine Clinical Features First Phase (3‐10) Days High grade fever Severe Headache Myalgias Abdominal pain Conjunctival suffusion Maculopapular rash Second Phase Meningitis Iridocyclitis Severe Leptospirosis (Weil’s Syndrome) Intense jaundice Renal failure Hypotension Hemorrhage ‐ Pulmonary,GI,ICH,Pericardium,Conjunctival Purpuric Rash Dr N Anand ANAND
- 53. Subconjunctival Hemorrhage with Icterus Purpuric Rash Dr N Anand ANAND
- 54. Bacterial Endocarditis Cause Staphylococcus Streptococcus Host Prosthetic Heart Valve Abnormal Heart Valve Intravenous Drug Users Clinical Features Vague Symptoms High Grade or Low Grade Fever Splenomegaly CVS‐ Appearance of new murmur Change in character of an existing murmur Worsening of cardiac failure Dr N Anand ANAND
- 55. Rash Janeway Lesions Painless Erythematous macules usually on palms and soles Osler Nodes Tender pink nodules on finger or toe pads Petechial Rash on Skin and Mucosa Splinter Haemorrhages on Nails Dr N Anand ANAND
- 57. CHIKUNGUNYA FEVER Cause Chikungunya virus Vector Aedes aegypti and Aedes albopictus Incubation period 2 to 4 days Clinical Features Acute stage ‐ sudden onset high fever, incapacitating polyarthritis, Maculopapular rash(20‐50%),Conjunctivitis Long‐lasting disabling polyarthritis Severe Polyarticular migratory arthralgias mainly involving small joints Axial involvement Chronic Rheumatism is common(weeks to more than 1 year) Rash Transient (between days 1 ‐4) Pruriginous maculopapular rash mostly on face, trunk, and extremities Diagnosis Serology(IgM for CHIKV) RT‐PCR Virus isolation Treatment Supportive Dr N Anand ANAND
- 58. Chikungunya Rash Dr N Anand ANAND
- 59. Erythema Marginatum(Rheumatic Fever) Cause Group A Streptococcus Host Patients with rheumatic fever Rash Erythematous annular papules and plaques over trunk and proximal extremeties Evanescent(evolving and resolving within hours) Clinical Features Fever, polyarthralgia Elevated ESR Carditis,Polyarthritis,Chorea,Erythema marginatum, Subcutaneous nodules Diagnosis Revised Jones Criteria Dr N Anand ANAND
- 62. Presence of 5 or more criteria, of which at least 2 are Major Major criteria Minor criteria Fever of at least 39C for at least one week Sore throat Arthralgias or arthritis for at least two weeks Lymphadenopathy Nonpruritic salmon coloured rash (usually over trunk or extremities while febrile) Hepatomegaly or splenomegaly Leukocytosis ( 10,000/microL or greater), with granulocyte predominance Abnormal liver function tests Negative tests for antinuclear antibody and rheumatoid factor Treatment‐ Oral Prednisolone Yamaguchi Preliminary criteria for classification of adult Still's disease. J Rheumatol. 1992 M Dr N Anand ANAND
- 64. SYSTEMIC LUPUS ERYTHEMATOSUS Cause Autoimmune, Multisystem Connective Tissue Disorder Clinical Manifestations Systemic Fever,Malaise,Anorexia,Nausea Musculoskeletal Arthralgias,Myalgias,Nonerosive Polyarthritis Cardiopulmonary Pleurisy,Pericarditis,Myocarditis,Endocarditis,Pleural Effusions Neurologic Organic Brain Syndromes,Psychosis,Seizures,Peripheral Neuropathy Renal Nephrotic Syndrome,Renal Failure Mucocutaneous Malar Rash(butterfly rash) ‐ Fixed Erythema over Malar eminences Discoid rash ‐ Erythematous Raised Patches with adherent keratotic scaling Photosensitivity,Oral ulcers Dr N Anand ANAND
- 65. MALAR RASH DISCOID RASH Dr N Anand ANAND
- 66. NODULAR ERUPTIONS • Disseminated Fungal Infection • Erythema Nodusum • SWEET’S Syndrome Dr N Anand ANAND
- 67. ERYTHEMA NODUSUM Cause Inflammation of the fat cells under the skin (streptococcal,fungal,mycobacterial,yersinial) Drugs(Sulfas,Penicillin,OCP) Sarcoidosis Idiopathic Pathogenesis Delayed hypersensitivity Immune Complex Mediated Clinical Features Fever, weakness and arthralgia. Tender red nodules on extensor surfaces Dr N Anand ANAND
- 68. Rash Large,violaceous,nonulcerative,tender,subcutaneous nodules Diagnosis Clinically Treatment Self Limiting,resolves in3‐6 weeks NSAIDS Treat the cause Dr N Anand ANAND
- 70. SWEET Syndrome (acute febrile neutrophilic dermatosis) SS is a reactive phenomenon and considered a cutaneous marker of systemic disease More common among women and among persons 30–60 years old Cause Idiopathic (Classic) Malignancy‐Hematological Yersinial infection Drug Induced Pregnancy Inflammatory Bowel Disease Dr N Anand ANAND
- 71. Presentation Sudden onset of fever An elevated white blood cell count Arthralgia or arthritis Eye involvement ‐ conjunctivitis or iridocyclitis Acute, tender, erythematous plaques, nodes, pseudovesicles and, occasionally, blisters with an annular or arciform pattern occur on the head, neck, legs, and arms. Lesions show dense infiltrates by neutrophil granulocytes on histologic examination Diagnosis Diagnosis of exclusion Neutrophilia Elevated ESR Skin biopsy Treatment Systemic corticosteroids(prednisone) Dr N Anand ANAND
- 72. Acute Febrile Neutrophilic Dermatosis Dr N Anand ANAND
- 73. PURPURIC ERUPTIONS Bacterial • Acute meningococcemia • Chronic Meningococcemia • Purpura Fulminans • Disseminated Gonococcal Infection • Thrombotic Thrombocytopenic Purpura • Hemolytic Uremic Syndrome Viral • Viral Hemorrhagic fever • Coxsackievirus A9 • Echovirus 9 • Epstein‐Barr virus • Cytomegalovirus Dr N Anand ANAND
- 74. MENINGOCOCCAL INFECTIONS Causative Agent Neissseria meningitidis Host and Environment Children, Asplenic Individuals Terminal Complement Component Deficiency(C5‐C8) Transmission Close contact by respiratory droplets or secretions Asymptomatic carriers Pathogenesis Colonization of URT ‐‐‐‐‐penetrate into bloodstream ‐‐‐‐ Go to CNS causing meningitis ( meningitis) / ‐ Infect the blood vessel (meningococcemia) Dr N Anand ANAND
- 75. Clinical Features Acute Illness High Fever ,Tachycardia Tachypnea Hypotension Rash Erythematous maculopapular rash initially Petechial or frankly purpuric over hours Large purpuric lesions in severe cases(Purpura Fulminans) Meningitis Fever, irritability and vomiting Neck Stiffness,Photophobia,Altered Sensorium,Seizures Septicemia High Mortality Shock Multiorgan Failure Disseminated Intravascular Coagulation Purpura Fulminans(large purpuric lesions and peripheral Ischemia) Meningococcal pneumonia Multilobar, rapidly evolving pneumonia Dr N Anand ANAND
- 77. Complications • Purpura fulminans • Neurologic sequelae • Deafness • CN VI, VII palsies • Bilateral Adrenal Hemorrhage(Waterhouse Friderichsen Syndrome) Chronic Meningococcemia Repeated episodes of petechial rash with fever,joint pain,features of arthritis, and splenomegaly May progress to Acute meningococcemia Dr N Anand ANAND
- 78. Diagnosis Leucocytosis CSF Studies • High WBC count,High Protein and /low Sugar • GramStainig,Culture sensitivity and PCR Analysis Blood Culture RT‐PCR of Blood Samples Treatment Fluid Resuscitation Empirical Antibiotic Therapy • Inj ceftriaxone 2g iv BD Prevention Quadrivalent Vaccines (Serogroups A, C, W‐ 135 and Y) Bivalent Vaccines (Serogroups C and Y) Dr N Anand ANAND
- 79. DISSEMINATED GONOCCAL INFECTION Causative Agent Neisseria gonorrhoeae (Resistant DGI strains) Clinical Features Low Grade Fever to High Grade Fever Skin Lesions Tenosynovitis and Suppurative Arthritis Genitals lesions usually not be present Rash Peripherally Papules or Petechiae evolving rapidly to hemorrhagic pustules with grey necrotic center Papules, bullae, pustules, and hemorrhagic lesions all may be present simultaneously Diagnosis Blood Culture Synovial Fluid Culture Treatment Inj Ceftriaxone 1 g IV q24h Dr N Anand ANAND
- 80. Gonococcal Arthritis (DGI) Dr N Anand ANAND
- 81. PURPURA FULMINANS Cause Disseminated Intravascular Coagulation Acute Severe Sepsis due N.meningitidis,S.pneumonia,H.influenza Protein C Deficiency Clinical Features Large Ecchymoses with sharply irregular shapes evolving in to Hemorrhagic Bullae and then in to Black Necrotic lesions Hypotension Features of DIC Diagnosis Purpuric lesions rapidly progress to Necrosis Increased FDP Deranged Coagulation Profile Thrombocytopenia Treatment Antibiotics Volume expansion FFP An acute, often fatal, thrombotic disorder due to coagulation in small blood vessels within the skin Dr N Anand ANAND
- 83. Cause Ebola virus and Marburg virus. Lassa Fever,Lujo Virus,South American Hemorrhagic Fever Dengue, Yellow fever, Kyasanur Forest disease Clinical Features Fever Bleeding diathesis Petechial Rash Hypotensive Shock(due to capillary leak) Diagnosis Leukopenia and Thrombocytopenia Increased Liver Enzymes Increased Hematocrit Antigen detection and Serology Treatment Fluid Resuscitation Whole Blood Transfusion VIRAL HEMORRHAGIC FEVER Dr N Anand ANAND
- 84. VESICULOBULLOUS OR PUSTULAR ERUPTIONS • Varicella • Variola • Primary Herpes Infection • Disseminated Herpes • Rickettsial Pox • Pseudomonas “hot tub” folliculitis Dr N Anand ANAND
- 85. Varicella Cause Varicella Zoster Virus Host Commonly in children Mode of transmission Droplet infection or Discharge by ruptured lesions Incubation Period 14‐21 Days Clinical features Low Grade Fever Rash Appears on trunk on 2nd day of illness ,spreads to face ,and limbs Rash Macules(2‐3mm) evolving to Papules,then vesicles on a erythematous base(“dew drops on a rose petal”) Pustules and then Crusting Lesions appear in crops Intensely pruritic Hemorrhagic lesions in immunocompromised Dr N Anand ANAND
- 86. Complications Herpes Zoster(reactivation of latent infection) Myocarditis Hepatitis Interstitial Pneumonitis Meningitis Acute glomerulonephritis Herpes Zoster Unilateral Vesicular Dermatomal eruption associated with Severe Pain Headache,fever and malaise Complications are common Diagnosis Clinical Tzanck Smear of vesicular fluid shows inclusion bodies Isolation of virus PCR Treatment Supportive Acyclovir Dr N Anand ANAND
- 89. Primary Herpes Infection Causative Agent Herpes simplex virus type 1 (HSV‐1) and type 2 (HSV‐2) Host Children and Young Adults for HSV‐1 Sexually active young adults for HSV‐2 Incubation Period 1‐26 days Clinical Conditions Herpetic gingivostomatitis Herpes labialis Herpes genitalis Herpes Encephalitis Herpes Oesophagitis Dr N Anand ANAND
- 90. Herpes Labialis Small blisters or cold sores on or around the mouth Fever Recurrence is common Sores heal within 2–3 weeks but virus remains dormant in the facial nerves Severe pharyngitis with dysphagia Lymphadenopathy Herpetic Gingivostomatitis Similar to herpes labialis with greater severity Herpes genitalis Clusters of genital sores consisting of inflamed papules and vesicles on the outer surface of the genitals Diagnosis Clinical Culture of the virus Direct fluorescent antibody Skin biopsy PCR Treatment Self‐limiting Antivirals Dr N Anand ANAND
- 91. Genital HerpesHerpes Labialis HERPETIC GINGIVOSTOMATITIS Dr N Anand ANAND
- 92. CONFLUENT DESQUAMATIVE ERYTHEMAS • Scarlet Fever • Kawasaki Disease • Streptococcal Toxic Shock Syndrome • Staphylococcal toxic Shock Syndrome • Staphylococcal Scalded Skin Syndrome Dr N Anand ANAND
- 93. SCARLET FEVER Causative Agent Streptococcus pyogenes (group A streptococcus) Host Commonly Children Mode of Spread Aerosol route Incubation Period 1‐4 Days Clinical Features Sore throat Fever Characteristic Rash, Bright red tongue ("strawberry" tongue) Forchheimer spots Paranoia Hallucinations Dr N Anand ANAND
- 94. Rash Diffuse Blanchable Erythema beginning on face and spreading to trunk and extremeties “Sand paper” texture to the skin Circumscribed Oral Pallor Accentuation of linear erythema in skin folds(Pastia’s lines) Desquamation in Second Week Dagnosis Clinical Examniation Leukocytosis with neutrophilia and eosinophilia High ESR and CRP Elevation of antistreptolysin O Complications Sepsis acute glomerulonephritis Rheumatic fever Erythema nodosum Treatment Antibiotics Dr N Anand ANAND
- 96. STREPTOCOCCAL TOXIC SHOCK SYNDROME Cause Streptococcus pyogenes(streptococcal pyrogenic exotoxins A and/or B or certain M types) Host In severe group A streptococcal infections(Necrotising fasciitis,Bacteremia) Pre‐existing skin infections with the bacteria. Clinical Features Hypotension Multiorgan Failure Bacteremia Rash Rash Generalized Erythroderma with desquamation and localized cellulitis with vesiclation or bulla formation Daignosis Clinical Examination Elevation of antistreptolysin O Treatment Supportive Management Antibiotics Dr N Anand ANAND
- 97. KAWASAKI DISEASE Cause Idiopathic Host Children under 5 years Clinical Features Acute Febrile illness Rash appears 3 days after fever Cervical lymphadenopathy Coronary Artery Vasculitis Erythema of the lips or oral cavity Bilateral nonsuppurative Conjunctivitis Rash Diffuse macular‐papular erythematous rash on the trunk Desquamation later Diagnosis Clinically 2D Echo or Coronary Angiography. Treatment Intravenous immunoglobulin and Corticosteroids Dr N Anand ANAND
- 98. STAPHYLOCOCCAL TOXIC SHOCK SYNDROME Cause Staphylococcus aureus(TSST 1,enterotoxin B or C) Host All ages, but most common in menstruating females Infection following childbirth, abortion, and surgery. Clinical Features High fever(104° F) Hypotension Malaise Confusion, which can rapidly progress to stupor, coma Multiple Organ Dysfunction Rash Diffuse erythema involving palms,mucosal surfaces Desquamation 7‐10 days in to illness Daignosis Clinical criteria, Vaginal and wound cultures Treatment ICU Care Antibiotics Dr N Anand ANAND
- 100. STAPHYLOCOCCAL SCALDED SKIN SYNDROME Cause Staphylococcus aureus(exotoxins A and B) Host Commonly Neonates Adults‐Immunosuppression,Renal Failure,Lymphoma Clinical Features Diffusse painful erythema Extensive areas of desquamation Perioral crusting and fissuring Irritability Nasal or Conjuctival Secretions Thin walled fluid filled blisters ‐ positive for Nikolsky's sign Daignosis Clinical Skin biopsy(intraepidermal separation) Isolation of S. aureus from blood,skin Treatment Supportive Antibiotics Dr N Anand ANAND
- 102. ERUPTIONS WITH ULCERS AND/OR ESCHARS • Rickketsial Infections • Tularemia • Anthrax Dr N Anand ANAND
- 103. Tularemia Anthrax Cause Francisella tularensis Bacillus anthracis Mode of Infection Exposure to ticks, biting flies, infected animals Exposure to infected animals or animal products, exposure to anthrax spores Rash Ulceroglandular form: erythematous, tender papule evolves into necrotic, tender ulcer with raised borders Maculopapular Rash may occur Pruritic papule evolving into painless ulcer surrounded by vesicles and then developing a central eschar with edema; residual scar Clinical Features Fever, headache, lymphadenopathy Fever,Lymphadenopathy, headache Dr N Anand ANAND
- 104. Necrotic ulcer of tularemia Inflamed Lymph Nodes Dr N Anand ANAND
- 107. •Most drug‐induced cutaneous reactions are mild and disappear when the offending drug is withdrawn •Diagnosed mainly from the medical history and clinical examination •Maculopapular /Morbilliform reuptions are most common • Urticaria are the second most common •Less commonly causes anaphylaxis,SJS orTEN Dr N Anand ANAND
- 109. Beta‐Lactam Antibiotics(mainly Penicillin) and Sulphonamides are the commonly associated Diagnosis is mainly clinical Treatment – Discontinuation of the drug Oral antihistamines and emollients Topical Glucocorticoids Dr N Anand ANAND
- 110. Drug induced Urticaria • Urticaria commonly referred to as hives, characterized by pale red,raised, well demarcated pruritic lesions of varying size • It may cause a burning or stinging sensation • Drug Induced can be due to • IgE dependent mechanism‐ usually occurs within minutes to 36 hours of drug exposure • Circulating Immune Complexes(Serum Sickness) occurs 6‐ 12 days after first exposure • Direct Mast Cell Degranulation Dr N Anand ANAND
- 113. SERUM SICKNESS • Serum sickness is a type III hypersensitivity reaction (immune complex–mediated) resulting from the injection of heterologous or foreign protein or serum. • After the initial exposure to a foreign antigen in the absence of a preexisting antibody, serum sickness can develop within 1‐2 weeks. Upon subsequent exposure,serum sickness develops sooner. The disease appears as the antibody formation begins • Characteristic Symptoms –Fever,Chills,Urticaria,Myalgias,Arthralgias and possibly renal or neurologic dysfunction Dr N Anand ANAND
- 114. Causes Drugs Allopurinol Barbiturates Captopril Penicillins Phenytoin Procainamide Cephalosporins Griseofulvin Penicillins Quinidine Streptokinase Sulfonamides Rituximab Ibuprofen Antitoxins Antivenoms Hormones from other species Streptokinase Vaccines Monoclonal Antibodies Dr N Anand ANAND
- 115. Clinical Features Develops 1‐3 weeks after initial exposure of the causative agent but can occur within 12‐36 hours in previously sensitized individuals Symptoms –(Lawley TJ, Frank MM. Immune complexes and allergic diseases) Fever/malaise ‐ 100% Blurred vision ‐ 37% Cutaneous eruptions ‐ 93% Myalgias ‐ 37% Arthralgias ‐ 77% Lymphadenopathy ‐ 17% Gastrointestinal complaints ‐ 67% Dyspnea/wheezing ‐ 20% Headaches ‐ 57% Dr N Anand ANAND
- 116. • Fever develops in almost all patients , preceding skin rash in 10‐20% of cases. The fever is characterized by high spikes that normalize within the same day • Rash are usually urticarial (92%) /serpiginous. They typically start on the anterior lower trunk or the periumbilical or axillary regions and spread to the back, upper trunk, and extremities • Renal manifestations ‐ proteinuria, microscopic hematuria, and oliguria;. • Cardiovascular Manifestations‐ myocardial and pericardial inflammation. • Neurologic manifestations ‐Peripheral neuropathy,Brachial plexus neuritis,optic neuritis,cranial nerve palsies,GBS Dr N Anand ANAND
- 118. Diagnosis‐ Mainly Clinical and History of exposure Treatment • Withdrawal of the offending agent • Anti‐inflammatories and antihistamines provide symptomatic relief • Corticosteroids‐ (oral prednisone,1‐2 mg /kg daily until disease resolves and taperd over 1‐2 weeks) • Plasmapheresis Dr N Anand ANAND
- 120. Causes Drugs associated with DRESS Phenytoin Phenobarbital Carbamazepine Lamotrigine Sulfasalazine Cefixime Celecoxib Vancomycin Minocycline Sulfamethoxazole Allopurinol Abacavir Amitriptyline Mexiletine Captopril Nevirapine Oxcarbazepine Hydroxychloroquine Dapsone Ibuprofen Dr N Anand ANAND
- 121. RegiSCAR inclusion criteria for DRESS syndrome. Three of the first four criteria required for diagnosis Acute Rash Fever > 38° C Lymphadenopathy in at least two sites Involvement of at least one internal organ Blood count abnormalities (lymphopenia or lymphocytosis, eosinophilia, thrombocytopenia) Hospitalization Reaction suspected to be drug‐related Dr N Anand ANAND
- 122. Rash Maculopapular eruption progressing to exfoliative erythroderma and profound edema Pustules may appear Treatment Immediate discontinuation of Suspected Drug Supportive care Corticosteroids Dr N Anand ANAND
- 124. Drugs Sulphonamides Macrolides Penicillin Barbiturates Carbamazepine Phenytoin Allopurinol Aspirin Infections Herpes simplex Mycoplasma pneumoniae Idiopathic Dr N Anand ANAND
- 125. Clinical Features Acute presentation Fever Itching and Burning at the site of eruption Lesions could be maculopapular evolving to plaques Target Lesions Central erythema surrounded by area of clearing and another rim of erythema Symmetric on extremeties( knees,elbows,palms,soles) and spreads centripetally EM Major – Extensive lesions with vesicles involving mucous membranes Dr N Anand ANAND
- 128. Causes Drugs Sulphonamides Phenytoin, Phenobarbitone Lamotrigine, Carbamazepine Allopurinol oxicam NSAIDs Nevirapine Dr N Anand ANAND
- 129. Fever> 39 degree celcius Painful Skin Lesions, Sore throat and conjunctivitis Erythematous and purpuric macules,sometimes target lesions Diffuse erythema progressing to bullae, with epidermal necrosis and sloughing Mucosal Involvement Nikolsky sign SJS<10 % epidermal necrosis TEN>30% epidermal necrosis Clinical Features Dr N Anand ANAND
- 133. References • Weber DI, Cohen MS, Fine JD. The acutely ill patient with fever and rash. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone, 1999:633–50 • Harrison's Principles of Internal Medicine • Evaluating the Febrile Patient with a Rash,Harry D. Mckinnon, jr., MAJ, MC, USA, and THOMAS HOWARD, COL, MC, USA,Am Fam Physician. 2000 Aug 15;62(4):804‐816. • Clinical Features and Etiology of Adult Patients withFever and Rash,Fehmi Tabak, M.D., Aysan Murtezaoglu, M.D., Omur Tabak, M.D.1, Resat Ozaras, M.D.,Bilgul Mete, M.D., Zekayi Kutlubay, M.D.2, Ali Mert, M.D., Recep Ozturk, M.D Vol. 24, No. 4, 2012,Ann of Dermatology Dr N Anand ANAND
- 134. • Cutaneous Drug reaction, Harrison's Principles of internal medicine • Washington Manual of Medical Therapeutics • Severe Adverse Cutaneous Reactions to Drugs,Jean Claude Roujeau, and Robert S. Stern,N Engl J Med 1994; 331:1272‐1285November 10, 1994,NEJM • Drug Fever from Antimicrobial Agents, Ruchi A. Patel, Pharm.D., Jason C. Gallagher, Pharm.D,Medscape • Lawley TJ, Frank MM. Immune complexes and allergic diseases. In: Middleton E Jr, ed. Allergy Principles and Practice. 4th ed. St. Louis, Mo: Mosby; 1993:990 Dr N Anand ANAND