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
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. 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
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. Treatment
• Antiviral treatment – Acyclovir
• Human varicella zoster immunoglobulin (ZIG) is
recommended for high-risk immunosuppressed
individuals
Fever With Rash
11
12. Prognosis
• Quite good excluded immunosuppressed patients
• Resolves spontaneously – self limited
• Mortality rate 2-3 per 100,000 cases
Fever With Rash
12
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. 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. • 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. 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. 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. 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. Fever With Rash
19
Red, cracked lips and conjunctiva inflammation
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. 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. Fever With Rash
Coronary angiogram demonstrating giant aneurysms of the
LAD with obstruction and giant aneurysms of the RCA with 27
area of severe narrowing
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. • 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. Fever With Rash
30
Evaluation of Suspected Incomplete Kawasaki Disease
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. 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. 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. 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. 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
