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