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 : ?
 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