Fever with rash by Dr.Eugene

Fever with Rash

Chooi Yuo Hao (Eugene)

Fe

ver

With

Ra

sh

1

•Varicella Zoster Virus (VZV)•Perinatally acquired varicella

•Kawasaki Disease

2

Fe

ver

With

Ra

sh

History Taking• Introduction• Chief complaints• HOPI• Past history (Medical and Surgical)• Birth history• Feeding history• Developmental history• Immunization history• Drug history• Family history• Social and environmental history

3

Fe

ver

With

Ra

sh

Physical examination• General examination• Systemic examination

4

Fe

ver

With

Ra

sh

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 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• Predisposed to severe group A streptococcus and

Staphylococcus aureus infection

Fe

ver

With

Ra

sh

5

• 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 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

Fe

ver

With

Ra

sh

Clinical Manifestation

7

Fe

ver

With

Ra

sh

Varicella lesion

8

Fe

ver

With

Ra

sh

Vesicular rash of chicken pox

9

Fe

ver

With

Ra

sh

Haemorrhagic chickenpox

Complications• Bacterial superinfection

• Staphylococcal• Streptococcal• May lead to toxic shock syndrome or necrotizing fasciitis

• Central nervous system• Generalized encephalitis• Aseptic meningitis

• Immunocompromised• Haemorrhagic lesions• Pneumonitis • Progressive and disseminated infection• Disseminated intravascular coagulation

10

Fe

ver

With

Ra

sh

Treatment• Antiviral treatment – Acyclovir • Human varicella zoster immunoglobulin (ZIG) is

recommended for high-risk immunosuppressed individuals

11

Fe

ver

With

Ra

sh

Prognosis• Quite good excluded immunosuppressed patients• Resolves spontaneously – self limited• Mortality rate 2-3 per 100,000 cases

12

Fe

ver

With

Ra

sh

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

acyclovir

13

Beware of admitting a chickenpox contact to a clinical area with

immunocompromised children

Fe

ver

With

Ra

sh

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• 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

Fe

ver

With

Ra

sh

• 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 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

Fe

ver

With

Ra

sh

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• 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 vaccine16

Fe

ver

With

Ra

sh

Kawasaki Disease• Also known as acute febrile mucocutaneous

syndrome• A systemic febrile condition affecting children

usually <5 years old• Aetiology remains unknown, possible bacterial

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 year17

Fe

ver

With

Ra

sh

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• 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

• Illness not explained by other disease process18

Fe

ver

With

Ra

sh

19

Fe

ver

With

Ra

sh

Red, cracked lips and conjunctiva inflammation

20

Fe

ver

With

Ra

sh

Congestion of bulbar conjunctiva

21

Fe

ver

With

Ra

sh

Strawberry tongue

22

Fe

ver

With

Ra

sh

Peeling of fingers

23

Fe

ver

With

Ra

sh

Desquamation of the fingers

24

Fe

ver

With

Ra

sh

Indurative edema

Other helpful signs• Indurated BCG scar• Perianal excoriation, irritability• Altered mental state• Aseptic meningitis• Transient arthritis• Diarrhoea, vomiting, abdominal pain• Hepatoslenomegaly• Hydrops of gallbladder• Sterile pyuria

25

Fe

ver

With

Ra

sh

Investigation• Full blood count

• Anaemia, leukocytosis, thrombocytosis

• ESR and CRP elevated• Serum albumin <3gdl; Raised alanine

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

Fe

ver

With

Ra

sh

27

Fe

ver

With

Ra

sh

Coronary angiogram demonstrating giant aneurysms of the LAD with obstruction and giant aneurysms of the RCA with

area of severe narrowing

Complication• Coronary vasculitis, usually within 2 weeks of

illness• Asymptomatic

• Myocardial infection• Myocardial infarction• Pericarditis• Myocarditis• Endocarditis• Heart failure• Arrhythmias

28

Fe

ver

With

Ra

sh

• Incomplete Kawasaki Disease (kindly refer to the 2nd edition of paeds protocol pg 115)

• Atypical Kawasaki Disease (kindly refer to the 2nd edition of paeds protocol pg 115)

29

Fe

ver

With

Ra

sh

30

Fe

ver

With

Ra

sh

Evaluation of Suspected Incomplete Kawasaki Disease

Treatment • Primary treatment

• IV Immunoglobulins 2 Gm/kg infusion over 10-12 hoursTherapy <10 days of onset effective in preventing coronary vascular damage

• Oral Aspirin 30 mg/kg/day for 2 weeks or until patient is afebrile for 2-3 days

31

Fe

ver

With

Ra

sh

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 until resolves

Alternative: Oral Dipyridamole 3-5mg/kg daily

32

Fe

ver

With

Ra

sh

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 1~2%

• Good prognosis for aneurysms <4mm

33

Fe

ver

With

Ra

sh

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• 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 sudden death

• Treatment – Intravenous immunoglobulin and aspirin

34

Fe

ver

With

Ra

sh

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

• 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

Fe

ver

With

Ra

sh

36

Fe

ver

With

Ra

sh