Fever and Rash

DJATNIKA SETIABUDI

Tropical Medicine Block/System

Medical Faculty
Padjadjaran University
 Introduction

Common problem in clinic

Wide range of severity :

self limited disease life-threatening

Wrong 1st suspicion fatal outcome

Knowledge of differential diagnosis !!!

 Differential Diagnosis (1)

1. Past history of infectious disease and

immunization
2. Type of pro-dromal period
3. Feature of the rash
4. Presence of pathognomic or other
diagnostic signs
5. Laboratory diagnostic tests
 Differential Diagnosis (2)

Feature of the rash :

Category:
- macular or maculo-papular :
Morbilli, Rubella, Roseola infantum, Scarlatina
- papulo-vesicular:
varicella, herpes zoster, variola
- petechial or purpuric: meningococcemia, DHF
Character : discrete or confluent
Distribution , Duration
The appearance associated with fever?
 Key Questions:

Acute or Chronic (Recurrent)?

When did it start?
Pattern of Spread?
Sick or Well?
Pruritic?
Medications?
Exposures?
Describe What You See
A. Pattern/Distribution
Diffuse or Localized?
Mucous Membranes?
Palms & Soles?
Exposed vs. Unexposed Areas?
B. Individual Lesions
Color
Size
Blanches?
Characteristics
C. Other Physical Findings
 Primary Lesions

Macule : Flat, cannot be palpated

Papule : Palpable solid lesions <1cm
Nodule : Palpable solid lesions >1cm
Vesicle : Raised, fluid-filled lesions <0.5cm
Bulla : Larger vesicle
Pustule : Purulent vesicle
Plaques: Aggregations of any of the above
primary lesions
 Secondary Lesions
(Resulting from infection, trauma, or therapy)

Scales
Ulcers
Excoriations
Fissures
Crusts
Scars
 TABLE 1
Common Primary Skin Lesions
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

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

Bulla :Same as vesicle, except lesion is more than 0.5 cm in diameter

Pustule : Circumscribed elevation of skin containing purulent fluid of variable

character (i.e., fluid may be white, yellow, greenish or hemorrhagic)
 MORBILLI
(Measles; Rubeola)

Acute infection, contagious, caused by morbilli

Virus ( Famili Paramyxoviridae)
3 stadia : Prodromal
Erupstion
Convalescens
Endemic in developing countries
Effective imunization program
cases decreasing
prone to older age group
 Pathology

Lesion particularly at :
- Skin
- Mucous membranes :
respiratory : nasopharyng, bronchi
digestive : oral cavity, intestine
- Conjungtiva
Serous exudate,
mononuclear cell predominant
 Clinical manifestations

Incubation period : 10 12 days

Stadium prodromal :

- Coryza, Cough, Conjungtivitis

- Koplik spots
- Fever
Stadium eruption :
- High fever : 40 40,50C
- Typical rash: maculopapular eritromatosus
Head truncus extremities
Stadium convalescens:

- rash : hyperpigmentation macule/squama

- sign and symptoms resolve
Diagnosis

Anamnesis :
- symptoms
- history : - contact
- imunization

Clinical signs: typical

Laboratorium :
- leukopenia,
- relative lymphocytosis
 Complication

Pneumonia / Bronchopneumonia ; Otitis media

CNS : - meningoensefalitis
- Subacute Sclerosing Pan Encephalitis
Persisten diarrhea
protein lossing enteropathy
Exaserbation of TBC
Keratoconjunctivitis blindness
Secondary bacterial infection of skin
Myocarditis
Noma
 Prognosis

Particularly good prognosis

CFR decreased

Mortality caused by complication

 Treatment

Symptomatic

Supportive

Vitamin A :
Unicef/WHO reccomendation

Management of complication
 Prevention

Active immunization:
- Measles vaccine
- when ? 9 months old
- booster: 15 months --> MMR

Passive immunization
RUBELLA (German Measles)
Acute infection, contagious, caused by rubela
virus (family Togaviridae)
prodromal sign : + / -
Rash : short periode 3 days
Typical sign: lymphadenopathy
post auricular suboccipital
posterior colli
Problems in pregnant women
Congenital rubella Syndrome
 Clinical Manifestation
Incubation period : 18 + 3 days

Mild prodromal sign:

- mild fever
- adolescent : more severe

Rash : maculopapular
face sentrifugal to
neck trunk extremities
24 hours all of body
resolve in 3rd day
Congenital rubella Syndrome

Depend on gestational age

Abortus
Stillbirth
Congenital anomaly

gravida 1 4 weeks : 61%

5 8 weeks : 26 %
9 12 weeks : 8%
Congenital rubella Syndrome

Opthalmologic : cataract Micropthalmia

Glaukoma - chorioretinitis

Cardiac : Septal Defect PDA

Neurologic : Meningoencephalitis
Microcephaly mental Retardation

Auditoric : sensorineural deafness

 Exanthem subitum
( Roseola infantum )

Acute infection caused by Human Herpes

Virus 6 ( some HHV 7 )

Mostly in infant

Sporadic ( sometimes epidemic)

Typical feature :
- Severity of clinical sign unproportionally with
degree of fever
- Simultaniously resolve of rash and clinical sign
 Clinical Manifestation

Incubation period : 7 17 days ( + 10 days )

Most common in 6 18 months old
Fever
- abruptly high ; 39,4 41,20C
- Duration: 1 5 days ( mostly 3 4 days )
- Convulsion can occur
Mild clinical sign :
- mild pharyngitis and coryza
Rash : not specific
macule / maculopapular ; rose colour :
chest > exremities and neck face
Appear while temperature has return to normal
Disappear on 1 2 days with normal skin
 Prognosis

Particularly good prognosis

Bad prognosis :
- hyperpyrexia with persistent convulsion
 Treatment

Symptomatic

Supportive

Prevention : ?
 Viral Exanthem
Summary Table
Viral Syndrome Causative Exanthem/Enanthem Age/Epidemiol Associated Symptoms
Virus ogy
Roseola HHV-6 Erythematous macules and Infant-Preschool High fever x 3 days, then rash.
(HHV-7) papules surrounded by Mild URI sx.
white halos. Complications: febrile sz.
Erythema Infectiosum Parvovirus B19 Erythematous School-age Low-grade fever
slapped cheeks, followed
by reticulate erythema on
body

Hand-Foot-and-Mouth Coxsackie A16, Oval vesicles on palms, Infant-Preschool Fever, sorethroat, respiratory
Disease A6; Enterovirus soles, buttocks; oral and GI sx.
71; others erosions.
Measles Measles Erythematous macules and Majority of cases Prodrome: Fever, Malaise,
papules; spread from head in US are Conjunctivitis, Cough, Coryza
down. White erosions on imported. Infectious complications.
buccal mucosa (Koplik
spots)

Rubella Rubella Pruritic pink macules and Majority are Fever, HA, URI sx,
papules, spread from head vaccinated. conjunctivitis,
down over 24 hrs. lymphadenopathy.
Petechial lesions on soft Congenital rubella syndrome.
palate (Forsheimers sign)
 SCARLET FEVER (SCARLATINA)

Grup A beta-hemolytic Streptococcus

pyrogenic toxin (erytrogenic toxin)
Clinical manifestation :
- Incubation period : 1 7 days (mean : 3 days)
- Acute symptoms:
high fever headache vomiting- chills
- Signs: severe pharyngitis
hyperemis edema eksudate- dysphagia
- Circum oral pallor dan Pastia lines
- white strawbey tongue desquamation
red strawberry tongue
Typical rash:
- Reddish macule / papule
blanching on pressure
- Firstly on axilla, groin and neck

24 hours all of body

- Severe disease : miliaria sudamina

- Petechiae can occur

- Desquamation occur from end of 1stweek

to 6th week of disease

Diagnosis

History and physical examination

Pharyngeal swab : bacterial culture

Serologic : ASTO/ ASLO/ ASO

Complete blood count : leukositosis
CRP increased or (+) : not specific
 Complication

Local spread / per continuitatum:

- Sinusitis Otitis media - Mastoiditis
- Retro / para parapharyngeal absces
- Bronchopneumonia
- Servical adenitis

Hematogenic spread:
- Meningitis Osteomyelitis
Arthritis (septic)

Non-suppurative (late) complication:

- Acute rhematic fever
- Acute Glomerulonephritis
 Treatment
Antibiotics :
- Penicillin group
- Allergy to penicillin :
Erythromycin lincomycin
Clindamycin- Cephadroxil

Symptomatic

Supportive

Management of Complication