Fever with Rash

Chooi Yuo Hao (Eugene)

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•Varicella Zoster Virus (VZV)•Perinatally acquired varicella

•Kawasaki Disease

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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

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Physical examination• General examination• Systemic examination

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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

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• 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

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Clinical Manifestation

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Varicella lesion

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Vesicular rash of chicken pox

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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

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

recommended for high-risk immunosuppressed individuals

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

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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

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Beware of admitting a chickenpox contact to a clinical area with

immunocompromised children

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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.

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• 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

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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

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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

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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

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Red, cracked lips and conjunctiva inflammation

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Congestion of bulbar conjunctiva

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Strawberry tongue

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Peeling of fingers

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Desquamation of the fingers

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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

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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

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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

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• 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)

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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

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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

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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

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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

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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

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