Approach to fever with rashes
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This document discusses several viral infections that can present with fever and rash, including measles, rubella, and chickenpox. It describes the causative agents, modes of transmission, incubation periods, clinical manifestations like rash appearance and progression, potential complications, treatments, and importance of vaccination.
Approach to fever with rashes
- 2. INTRODUCTION FEVER WITH RASH IS A COMMON VEXING PROBLEM. IT MAY SIGNIFY A SERIOUS DISORDER (MENINGOCOCCEMIA OR DENGUE HAEMORRHAGIC FEVER) OR MAY BE ASSOCIATED WITH MINOR DRUG ALLERGY THERE ARE NON INFECTIOUS CAUSES ALSO
- 3. CAUSES MACULAR OR MACULOPAPULAR RASH VIRUS ADENOVIRUS, MEASLES RUBELLA, ROSEOLA ERYTHEMA INFECTIOSUM EPSTEIN BARR VIRUS ECHO VIRUS, HBV HIV BACTERIA ERYTHEMA MARGINATUM(RHEUMATIC FEVER) SCARLET FEVER ( GROUP A STREPTOCOCCUS) ERYSIPELAS ARCANOBACTERIUM HAEMOLYTICUM SECONDARY SYPHILIS LEPTOSPIROSIS, PSEUDOMONAS MENINGOCOCCAL INFECTION SALMONELLA TYPHI, LYME DISEASE MYCOPLASMA PNEUMONIAE
- 4. CONTD. RICKETTTSIAE ROCKY MONTAIN SPOTTED FEVER TYPHUS(SCRUB, ENDEMIC) EHRLICHIOSIS OTHER KAWASAKI DISEASE RHEUMATOID ARTHRITIS DRUG REACTION
- 5. DIFFUSE ERYTHRODERMA BACTERIA SCARLET FEVER (GROUP A STREPTOCOCCUS) STAPHYLOCOCCAL SCALDED SYNDROME TOXIC SHOCK SYNDROME ( STAPHYLOCOCCUS AUREUS) FUNGI CAANDIDA ALBICANS OTHER KAWASAKI SYNDROME URTICARIAL RASH VIRUSES EPSTEIN BARR VIRUS HBV HIV BACTERIA M. PNEUMONIAE GROUP A STREPTOCOCCUS OTHER DRUG REACTION
- 6. VESICULAR, BULLOUS, PUSTULAR VIRUSES HERPES SIMPLEX VIRUSES VARIZELLA ZOSTER VIRUS COXACKIEVIRUSES BACTERIA STAPHYLOCOCCAL SCALDED SKIN SYNDROME STAPHYLOCOCCAL BULLOUS IMPETIGO RICKETSSIAE RICKETSSIALPOX OTHERS TOXIC EPIDERMAL NECROLYSIS ERYTHEMA MULTIFORME(STEVENES- JHONSON SYNDROME)
- 7. PETECHIAL PURPURIC VIRUSES ADENOVIRUS ATYPICAL MEASLES CONGENITAL RUBELLA CONGENITAL CMV,ENTERO VIRUS PARVO VIRUS B 19 HIV, HAEMORRHAGIC FEVER VIRUS BACTERIA SEPSIS(MENINGOCOCCAL, GONOCOCCAL, PNEUMOCOCCAL, HAEMOPHILUS INFLUENZAE TYPE B) INFECTIVVE ENDOCARDITIS) ECHTHYMA GANGRENOSUM( RICKETSSIAE ROCKY MONTAIN SPOTTED FEVER EPIDEMIC TYPHUS EHRLICHIOSIS FUNGI NECROTIC ESCHAR(ASPERGILLUS, MUCOR) OTHERS VASCULITIS, THROMBOCYTOPENIA HENOCH-SCHONLEIN PURPURA MALARIA
- 8. ERYHTMA NODOSUM VIRUS EPSTEIN BARR VIRUS HBV BACTERIA GROUP A STREPTOCOCCUS MYCOBACTERIUM TUBERCULOSIS YERSINIA CAT SCRATCH DISEASE FUNGI COCCIDIOMYCOSIS HISTOPLASMOSIS OTHERS SARCOIDOSIS INFLAMMATORY BOWEL DISEASE ESTROGEN CONTAINING OCP SLE BEHCETS DISEASE
- 9. Uncommon disease- scarlet fever, Kawasaki disease
- 10. HISTORY AGE DURATION DISTRIBUTION AND PROGRESSION OF THE RASH TRAVEL/ LOCATION SICK CONTACTS HISTORY OF DRUG INTAKE VACCINATIONS PREVIOUS EXANTHEMS SEASON INVOLVEMENT OF MUCOUS MEMBRANE ASSOCIATED SYMPTOMS- ITCHING( CHICKEN POX)- FEVER(INFECTIOUS CAUSES)-PAIN
- 11. DETAILS OF RASHES SITE OF ONSET DIRECTION OF SPREAD PRESENCE OR ABSENT OF PRURITIS RELATIONSHIP WITH FEVER AND RASH IMPORTANT TO KNOW ANY TOPICAL OR ORAL MEDICATION APPLIED OR NOT.
- 12. EXAMINATION PATIENT’S VITAL SIGN AND GENERAL APPEARANCE SIGN OF TOXICITY LYMPHADENOPATHY ORAL, GENITAL OR CONJUNCTIVA LESION HEPATO-SPLENOMEGALY EVIDENCES OF EXCORIATION AND TENDERNESS SIGN OF NECK RIGIDITY OR NEUROLOGICAL DYSFUNCTION.
- 13. INVESTIGATIONS ROUTINE INVESTIGATIONS o TOTAL COUNT , DIFFERENTIAL LEUCOCYTE COUNT o ESR
- 14. MEASLES ETIOLOGY- SINGLE STRANDED PARAMYXO VIRUS MODE OF TRANSMISSION: CONTACT WITH SECRETIONS OR DROPLETS OF AN INFECTED CHILD. PERIOD OF INFECTIVITY: 4 DAYS PRIOR TO AND 5 DAYS AFTER APPEARANCE OF THE RASH. CLINICAL MANIFESTATIONS: o AN INCUBATION STAGE 10-12 DAYS o PRODROMAL STAGE WITH AN ENANTHEM (KOPLIK SPOTS), USUALLY LASTS 3-5 DAYS. KOPLIK SPOTS ARE GRAYISH WHITE DOTS ON AN ERYTHEMATOUS BASE ON THE ANTERIOR PORTION OF THE BUCCAL MUCOSA. WITH APPEARANCE OF RASH, KOPLIK SPOTS START TO DISAPPEAR.
- 15. FINAL STAGE STARTS WITH A MACULOPAPULAR RASH ACCOMPANIED BY HIGH FEVER. THE RASH STARTS BEHIND THE EARS, AND ALONG THE HAIRLINE. THEN THE RASH SPREADS ON THE FACE, NECK, UPPER ARMS, AND UPPER PART OF THE CHEST WITHIN THE FIRST 24 HOURS. ON 2ND DAY. THE RASH APPEARS ON THE BACK, ABDOMEN, ARMS AND THIGHS. ON 3RD DAY. IT REACHES THE FEET AND BEGINS TO FADE ON THE FACE. AN ABRUPT DROP IN TEMPERATURE TO NORMAL. THE RASH FADES DOWNWARD IN THE SAME SEQUENCE IN WHICH IT APPEARED
- 16. DIAGNOSIS: CLINICAL FEATURES BUT LABORATORY TESTS IS RARELY NEEDED. LEUKOCYTIC COUNT TENDS TO BE LOW WITH A RELATIVE LYMPHOCYTOSIS. LEUCOCYTOSIS IS INDICATIVE OF SECONDARY BACTERIAL INFECTION. COMPLICATIONS: THE MAIN COMPLICATIONS OF MEASLES ARE OTITIS MEDIA AND PNEUMONIA. ENCEPHALITIS; DIARRHEA AND DYSENTERY. ACTIVATION OF A TUBERCULOUS FOCUS.
- 17. TREATMENT SUPPORTIVE THERAPY: ANTIPYRETICS (PARACETAMOL) BED REST AND AN ADEQUATE FLUID INTAKE ARE INDICATED. A NOURISHING EASILY DIGESTED DIET AND PROPER CLEANLINESS. VITAMIN A: A SINGLE DOSE OF 50,000 TO 200,000 IU. A BROAD SPECTRUM ANTIBIOTIC IN PRESENCE OF INFECTIONS. PREVENTION: ISOLATION SHOULD BE MAINTAINED FROM THE 7TH DAY AFTER EXPOSURE UNTIL 5 DAYS AFTER THE RASH HAS APPEARED. MEASLES VACCINE. POST-EXPOSURE PROPHYLAXIS.
- 18. RUBELLA ETIOLOGY: RUBELLA VIRUS (AN RNA VIRUS). INCUBATION PERIOD: 2-3 WEEKS. MODE OF TRANSMISSION: DROPLET INFECTION OR DIRECT CONTACT WITH A CASE PRODROMAL STAGE: VERY SHORT AND MILD THAT IT GOES UNNOTICED. INFECTIVITY : NOT AS CONTAGIOUS AS MEASLES. VIRUS IS PRESENT IN NASOPHARYNGEAL SECRETIONS, BLOOD, FAECES AND URINE. VIRUS HAS BEEN RECOVERED FROM THE NASOPHARYNX 7 DAYS BEFORE EXANTHEMA AND 7-8 DAYS AFTER ITS DISAPPEARANCE. INFANTS WITH CONGENITAL RUBELLA ARE CONTAGIOUS FOR ATLEAST 10-12 MONTHS.
- 19. CLINICAL MANIFESTATIONS AGE: ANY AGE, PEAK INCIDENCE 5-14 YEARS LYMPHADENOPATHY IS EVIDENT AT LEAST 24HR BEFORE THE RASH APPEARS. THE EXANTHEM BEGINS ON THE FACE AND SPREADS QUICKLY ON THE FIRST DAY. 2ND DAY. THE RASH IS CONFLUENT AND PINPOINT LIKE THAT OF SCARLET FEVER WITH MILD ITCHING. 3RD DAY. THE RASH GENERALLY DISAPPEARS WITH MINIMAL DESQUAMATION AND NO SCARING. RUBELLA WITHOUT RASH MAY OCCUR AS FEVER WITH ENLARGED TENDER LYMPHADENOPATHY WHICH MAY PERSIST FOR A WEEK OR MORE.
- 20. COMPLICATIONS: COMPLICATIONS ARE RELATIVELY UNCOMMON IN CHILDHOOD. ENCEPHALITIS SIMILAR TO THAT SEEN WITH MEASLES POLYARTHRITIS PROPHYLAXIS: ACTIVE IMMUNIZATION (MMR VACCINE) -MMR VACCINE SHOULD NOT BE GIVEN TO PREGNANT WOMEN; VACCINATED WOMEN SHOULD AVOID PREGNANCY FOR 3 MONTHS AFTER VACCINATION. NATURAL INFECTION GIVES LIFE- LONG IMMUNITY. PASSIVE IMMUNIZATION. IT IS NOT INDICATED EXCEPT IN NON- IMMUNE PREGNANT WOMEN. IMMUNE SERUM GLOBULIN (ISG) IN BIG DOSES IS GIVEN I.M WITHIN ONE WEEK OF EXPOSURE. TREATMENT: 1- ANTIPYRETICS FOR FEVER. 2- TREATMENT OF COMPLICATIONS
- 21. CONGENITAL RUBELLA IF RUBELLA DEVELOPS DURING THE FIRST TRIMESTER OF PREGNANCY, (WHICH IS THE PERIOD OF ORGANOGENESIS). TRANSPLACENTAL CONGENITAL INFECTION FROM INFECTED MOTHER. FEATURES OF CONGENITAL RUBELLA SYNDROME: 1-INTRAUTERINE GROWTH RETARDATION, SMALL FOR GESTATIONAL AGE AND FAILURE TO THRIVE 2-NERVE DEAFNESS 3- MICROCEPHALY AND MENTAL RETARDATION 4- CONGENITAL HEART DISEASE (PDA, VSD) 5- CATARACT, GLAUCOMA, AND CLOUDY CORNEA 6- THROMBOCYTOPENIC PURPURA, HEPATOSPLENOMEGALY, AND OSTEOPATHY
- 22. CHICKEN POX (VARICELLA) THIS IS A HIGHLY CONTAGIOUS INFECTION CHARACTERIZED BY A PLEOMORPHIC RASH. ETIOLOGY: VARICELLA-ZOSTER VIRUS WHICH CAUSE CHICKEN POX IN A NON IMMUNE AND HERPES ZOSTER IN A PARTIALLY IMMUNE INDIVIDUAL. MODE OF INFECTION: 1. DIRECT CONTACT. 2. DROPLET INFECTION. 3. AIR BORNE. PERIOD OF INFECTIVITY: EXTENDS FROM ONE DAY BEFORE THE ONSET OF RASH TILL CRUSTED. INCUBATION PERIOD: 2-3 WEEKS.
- 23. CLINICAL MANIFESTATIONS: AGE: ANY AGE , THE MOST COMMON FROM 5-10 YEARS. PRODROMAL STAGE: VERY MILD AND SHORT. ERUPTION STAGE: (PLEOMORPHIC RASHES), ALL FORMS OF LESIONS BEING PRESENT. THE RASH APPEARS AS CROPS OF MACULES WHICH WITHIN HOURS PASS THROUGH A PAPULAR STAGE, THEN PROGRESS TO DEVELOP VESICLES AND PUSTULES. PRURITUS MAY BE INTENSE. -THE RASH MAY APPEAR ON MUCOUS MEMBRANES WITH ULCERATION IN THE MOUTH.
- 24. COMPLICATIONS: SECONDARY BACTERIAL INFECTION OF SKIN LESIONS. HEMORRHAGIC COMPLICATIONS: THROMBOCYTOPENIA, PURPURA, HEMATURIA, AND GASTROINTESTINAL HEMORRHAGE. ENCEPHALITIS AND CEREBELLAR ATAXIA. REYE SYNDROME: ENCEPHALOPATHY AND HEPATIC DYSFUNCTION.
- 25. TREATMENT: LOCAL AND SYSTEMIC ANTIHISTAMINIC TO ALLEVIATE ITCHING. NON- ASPIRIN ANTIPYRETICS (E.G. PARACETAMOL). LOCAL APPLICATION OF CALAMINE LOTION. PATIENTS AT RISK OF SEVERE CHICKENPOX SHOULD RECEIVE ACYCLOVIR (ANTIVIRAL AGENT). TREATMENT OF COMPLICATIONS.