Fever & Rash

Fever & Rash

1. Dr. Badriya Al- mahrouqi Senior Specialist – Family Physician FEVER & RASH

2. Outline Definitions Approach to patient with fever & rash Differential diagnosis for fever and rash Management of different cases of fever and rash

3. WHAT IS ? FEVER - temporary ↑ in the body’s temperature in response to some disease or illness (37.5°C) RASH - temporary eruption of the skin - discrete red spots / generalized reddening - accompanied by itching

4. MACULE The lesion in this image is a macule because it is flat, nonpalpable , and of small diameter.

5. Patch A lesion which is more than 0.5cm in diameter with an area of colour change.   

6. PAPULES Solid, raised lesion up to 0.5 cm in greatest diameter

7. NODULE Similar to papule but located deeper in the dermis or subcutaneous tissue; differentiated from papule by palpability and depth, rather than size

8. PUSTULE Circumscribed elevation of skin containing purulent fluid of variable character (i.e., fluid may be white, yellow, greenish or hemorrhagic)

9. VESICLES Circumscribed, elevated, fluid-containing lesion less than 0.5 cm in greatest diameter; may be intraepidermal or subepidermal in origin

10. BULLA Same as vesicle, except lesion is more than 0.5 cm in greatest diameter

11. ' purpura ' purpura ‘ is a purplish discolouration of the skin produced by small bleeding vessels near the surface or in the mucous membranes, especially of the mouth and in the internal organs. When purpura spots are very small (<1 cm in diameter), they are called petechiae or petechial haemorrhages . Larger , deeper purpura are referred to as ecchymoses or bruising.

12. PLAQUE elevated, palpable lesions > 10 mm in diameter

13. wheal A wheal is an oedematous papule or plaque caused by swelling in the dermis.

14. scale heaped-up accumulations of horny epithelium

15. Approach To Patient With Fever & Rash

16. Approach To Patient With Fever & Rash FOUR general issues are important in the initial evaluation of fever & rash: ASSESS SEVERITY OF ILLNESS CONFIRMATION OF FEVER & DETERMINE TYPE OF RASH NARROW THE RANGE OF POSSIBLE CAUSES DO THE PROPER ACTION PLAN

17. TRIAGE ASSESS SEVIRITY OF ILLNESS Confirmation of fever

18. warning signs Decreased alertness Decreased BP Increased HR h/o seizure Petechial rash Neck stiffness Dehydration

19. CONFIRMATION OF FEVER RULE OUT: outside factors: Body temperature is affected by dress –sleep –exercise-nutrition – place temperature. Accepted values: Rectal temperature :above (38ºC) Oral temperature: above (37.8ºC) Axillary temperature: above (37.2ºC) Forehead temperature: above (38ºC) Ear temperature (38ºC) in rectal mode (37.5ºC) in oral mode

20. HISTORY

21. HISTORY History Of Present Illness: Ask about MUSCATS M ODE OF FEVER: DURATION & FLACTUWATION –SEVIRITY U SED MEDICATION AND INVESTIGATION S YMPTOMS : rash – jaundice – lymphnodes -PAIN- COUGH C ONTACT WITH ANIMALS AND SICK PEOPLE A dmission T RAVEL HISTORY: include location, time since return, locale ( eg , in back country, only in cities), vaccinations received before travel, and any use of prophylactic antimalarial drugs. All patients should be asked about possible exposures ( eg , via unsafe food or water, insect bites, animal contact, or unprotected sex). S ex - unprotected

22. HISTORY Review of systems : Symptoms and signs of differential diagnosis

23. DIFFERENTIAL DIAGNOSIS OF FEVER WITH RASH LESION PATHOGENS OR INFECTION Maculopapular rash: central distribution VRS - Measles, rubella, roseola , erythema infectiosum , EBV, echovirus, HBV, HIV BACT - Erythema marginatum , scarlet fever, erysipelas, 2° syphilis, leptospirosis, Lyme dzs , RICK – Rocky Mountain Spotted fever, Typhus OTH – RA, Kawasaki dis , drug rxn

24. DIFFERENTIAL DIAGNOSIS OF FEVER WITH RASH LESION PATHOGENS OR INFECTION Maculopapular rash: peripheral distribution – ERYTHEMA MULTIFORME VRS - HSV, EBV, echovirus, BACT - , 2° syphilis, leptospirosis, Lyme dzs , RICK – Rocky Mountain Spotted fever OTH – RADIATION RX, drug rxn , Meningococcemia, and dengue fever

25. b) Diffuse erythema with desquamation Scarlet fever TOXIC SHOCK SYNDROME AND SCALDED SKIN SYNDROME

26. d) vesicular, pustular , bullous VRS - HSV, VZV, Coxsackievirus BACT - Staph.SSS , Staph. Bullous impetigo, Strep. crusted impetigo OTH - Toxic epidermal necrolysis , Steven-Johnson Syndrome. RICK – Rickettsial pox e) Petechial - purpuric VRS - Atypical measles, congenital rubella, CMV, enterovirus , HIV, HF viruses BACT - Sepsis (meningococcal, gonococcal , pneumococcal, Hib ), IE OTH - Vasculitis, thrombocytopenia, Henoch-Schönlein purpura , malaria Generalised bone marrow failure ( eg , leukaemia , aplastic anaemia , myeloma , marrow infiltration by solid tumours ).

27. f) Erythema Nodosum VRS - EBV, HBV BACT - Group A Streptococcus TB, yersinia , Cat-Scratch Dzs FUNGI - Coccidiomycosis , histoplasmosis OTH - Sarcoidosis , Inf. Bowel dzs , OCP, SLE, Behçet dzs

28. HISTORY Past medical history : Known disorders that predispose to infection (eg, HIV infection, diabetes, cancer, organ transplantation, sickle cell disease, valvular heart disorders—particularly if an artificial valve is present) Other known disorders that predispose to fever (eg, rheumatologic disorders, SLE, gout, sarcoidosis, hyperthyroidism, cancer)

29. HISTORY Past medical history : Drug history should include specific questions about the following: Drugs known to cause fever Drugs that predispose to increased risk of infection ( eg , corticosteroids, anti-TNF drugs, chemotherapeutic and antirejection drugs, other immunosuppressant) Illicit use of injection drugs Vaccination history, particularly against hepatitis A and B and against organisms that cause meningitis, influenza, or pneumococcal infection, should be noted . SURGICAL HISTORY:

30. HISTORY SOCIAL HISTORY: SMOKING & ALCOHOL USE SEXUAL HISTORY OCUBATIONAL HISTORY (habits) TRADITIONAL EVENTS TRAVEL HISTORY

31. In PHYSICAL EXAMINATION : GENERAL STATUS SKIN RASH Distribution pattern-MORPHOLOGY-CONFIGURATION C ) Systemic examination searching for complications

32. Most common finding with fever Stiff neck or bulging fontanel (meningitis) Strawberry tongue : scarlet fever – Kawasaki disease KOPLIK SPOTS: MEASLES FORSCHHEIMER SPOTS: RUBELLA PEELING IF SKIN OF FINGERS AND FOOT:SCARLET FEVER - KAWASAKI

33. Management of different cases of fever and rash

34. CASE SCENARIO History: 9 mo old girl, good general health condition Progressive fever for 5 days (max. 39.50C) Coryza , exudative conjunctivitis Severe cough and irritability No diarrhea , no vomiting No recent travel, no pets Rashes - over trunk, abdomen and back - appear 4 days after onset of fever - not elevated and no itching - blanching on pressure

35. Confluent maculo-papular rash all over the body

36. MEASLES Characteristic EXPLAINATION Causative Agent Measles virus ( ssRNA paramyxovirus ) Host Human Invade Upper respiratory tract, regional LN Transmited by Large respiratory droplets with no fomites (close contact transm .) Virus present Respiratory secretion, blood, urine Period of communicability Contagious from 5 days before to 4 days after the appearance of rash.

37. CLINICAL MANIFESTATION Divided into 4 phases :- Incubation - IP = 8 to 12 days from exposure to the onset of symptoms, 14 days from exposure to the onset of rash. Prodromal (catarrhal) - cough, coryza , conjunctivitis (Stimson line) Koplik spots (buccal mucosa) Exanthematous (rash) - accompanied by high grade fever (40-40.5°C) - The rash starts behind the ears and on the forehead at the hair line spread down to the leg (descending) - show severity of the illness d) recovery

38. MACULAR RASH KOPLIK SPOTS CONJUNCTIVITIS

39. Other manifestations : Cervical lymphadenitis Spleenomegaly Abdominal pain encephalitis Mesenteric lymphadenopathy Otitis media Pneumonia common in infants Diarrhea Liver involvement – common in adult

40. COMPLICATIONS Acute otitis media (10-15%) Interstitial pneumonia (50-75% pathological chest XR) Myocarditis and pericarditis Encephalitis (1/1000 cases) 7-10 days after rash Subacute sclerosis panencephalitis Mesenteric lymphadenitis

41. Action plan: 1- Collect Samples :Take 2 Blood Sample One Serum And Heparinized – Throat Or Nasopharyngeal Swab- Urine Sample And Send It To Central Lab – If No Lab Send To Hospital 2- Notify 3 – Give Supportive Care – ASSESS NEED FOR ADNISSION OTHER WISE DISCHARGE HOME

42. MANAGEMENT TREATMENT Routine supportive care maintain adequate hydration antipyretics IV ribavirin (severe infection) High dose for vitamin A supplementation Antibiotics for conjunctivitis-otitis media - pneumonia

43. PREVENTION MMR Live attenuated measles vaccine 1 st dose : 12-15 month of life 2 nd dose : 18 months old * Contraindicated for severe immunosupression patient

44. RUBELLA Characteristic EXPLAINATION Causative Agent Rubella virus ( ssRNA , togavirus family) Host Human Invade Respiratory epithelium Transmited by Susceptible contact Infection in utero (congenital rubella synd ) during the 1 st trimester Virus present Nasopharyngeal secretion, urine Period of communicability contagious from 2 days before until 5 to 7 days after the onset of rash

45. CLINICAL MANIFESTATION IP = 14 to 21 days Rashes - begins on the face, spreads down to the body and lasts far three days. Retroauricular , posterior cervical, posterior occipital lymphadenopathy Erythematous , maculopapular , discrete rashes

46. Forschheimer spots (rose-colored spots on the soft palate) Mild pharyngitis Conjunctivitis Anorexia Headache Low grade fever Polyarthritis

47. Erythematous maculopapular discrete rash Forschheimer spots

48. COMPLICATIONS Rarely complicated compared to measles pregnancy – congenital rubella syndrome - IUGR - cataracts - deafness - patent ductus arteriosus (PDA)

49. PRINCIPLE OF MANAGEMENT TREATMENT No specific therapy Routine supportive care Congenital Rubella Syndrome baby should be isolated PREVENTION Live attenuated MMR vaccine Children at age 12-15 months of life Children at age 4-6 yrs old Pregnant woman should be immunized after delivery

50. Clinical case History: 5 y old boy, no special past medical history Low grade fever (38.30C) for 48 h Attends school No travel history No pets Vesicular rash on the trunk and face

51. Varicella (chickenpox) Causes: Varicella zoster virus (VZV, herpesvirus family) Human are the only natural host Chickenpox ( vericella ) = manifestation of primary infection Highly contagious among susceptible individuals; secondary attack rate is more than 90%) Contagiosity : 2 days before to 7 days after the onset of the rash, when all lesions are crusted

52. Peak age: 5 to 10 years old Peak seasonal infection: late winter and spring Transmission: direct contact, droplet, and air Incubation period: 14-16 days

53. Clinical manifestation Prodromal symptoms: fever, malaise , anorexia ( preceed the rash by 1 day) Characteristic rash : small red papules> Erythematous papules> vesicular> vesicles ulcerate, crust and heal (new crops appear for 3-4 days) Pattern of rash: beginning on the trunk followed by the head, face, and less commonly the extremities Pruritus is universal and marked Lesions may also present on mucosa membranes Lymphadenopathy may be generalized

54. Complication More severe for neonates, adults, and immunocompromised persons. - Secondary infection of skin by streptococci pr staphylococci Thrombocytopenia and haemorragic lesions or bleeding may occur ( varicella gangrenosa ) Pneumonia (15-20% 0f healty adults and immunlcompromised persons, uncommon in healthy children) Myocarditis , pericarditis , orchitis , hepatitis, ulcerative gastritis, glomerulonephritis and athritis may complicate Reye syndrome may follow varicella (aspirin use is contraindicated) Neurological complication: post infectious enencephaly , cerebellar ataxia, nystagmus and tremor.

55. Congenital infection -characteristic: low birth weight, cortical atrophy, seizure, mental retardation, chorioretinitis , cataracts,microcephaly Perinatal infection -severe form of noenatal varicella TREATMENT: Symptomatic therapy: Nonaspirin antipyretics, cool baths, careful hygiene Antiviral treatment: acyclovir, famciclovir , valacyclovir

56. Prevention Children with chickenpox should not return to school until all vesicle have crusted Live attenuated varicella (primary prevention) Passive immunity by VZIG (secondary prevention) for: Susceptible pregnant women & immunocompromised patient New born of mother infected 5ds before delivery or 2 ds after delivery

57. Herpes Zoster After the primary infection, the varicella-zoster virus lies dormant in the dorsal root ganglia. Herpes zoster is caused by reactivation of the virus. incidence increases significantly with age and in immunocompromised patients. The characteristic vesicular rash of herpes zoster usually affects a single dermatome and rarely crosses the midline A prodrome of unusual skin sensations may evolve into pain, burning and paresthesias , which precede the rash by two to three days.

58. complication Pain is the most debilitating feature of herpes zoster, and postherpetic neuralgia is the most common long-term complication. Other potential complications include: secondary infection , meningo -encephalitis, transverse myelitis, pneumonitis, hepatitis , myocarditis, pancreatitis, esophagitis, cystitis, granulomatous arteritis, conjunctivitis and Ramsay Hunt syndrome (herpes zoster involving the facial and auditory nerves).

59. Treatment Medications used include: steroids , analgesics, anticonvulsants , antiviral agents.

60. Hand,foot and mouth disease

61. Hand,foot and mouth disease most often occurs in children under 10 years old. Causes: coxsackie virus A16, enterovirus 71 (EV71) and other enteroviruses . The enterovirus group includes polioviruses, coxsackieviruses , echoviruses and other enteroviruses . more frequent in summer and early autumn (in temperate countries)

62. moderately contagious. A person is most contagious during the first week of the illness . transmitted from person to person via direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons . (incubation period) is 3 to 7 days. Fever is often the first symptom of HFMD followed by blister/rash.

63. Clinical manifestation mild fever, poor appetite, malaise ("feeling sick"), and frequently a sore throat. One or 2 days after the fever begins, painful sores develop in the mouth. They begin as small red spots that blister and then often become ulcers. They are usually located on the tongue, gums, and inside of the cheeks. The skin rash develops over 1 to 2 days with flat or raised red spots, some with blisters on the palms of the hand and the soles of the feet .

64. Blister on the palms of the hands Blister on the soles of the feet Blister then become ulcer on the inner gums Blister on the dorsum of the feet

65. C omplication HFMD caused by coxsackie virus A16 infection is a mild disease and nearly all patients recover within 7 to 10 days. Complications are uncommon. HFMD caused by Enterovirus EV71 may be associated with neurological complications such as aseptic meningitis and encephalitis

66. Treatment no specific effective antiviral drugs and vaccine available for the treatment of HFMD. Symptomatic treatment is given to provide relief from fever, aches, or pain from the mouth ulcers. Dehydration is a concern because the mouth sores may make it difficult and painful for children to eat and drink .

67. Prevention good hygienic practices. Preventive measures include: a. Frequent hand washing, especially after diaper changes, after using toilet and before preparing food, b. Maintain cleanliness of house, child care center, kindergartens or schools and its surrounding, c. Cleaning of contaminated surfaces and soiled items with soap and water, and then disinfecting them with diluted solution of chlorine-containing bleach (10% concentration), d. Parents are advised not to bring young children to crowded public places such as shopping centers, cinemas, swimming pools, markets or bus stations, e. Bring children to the nearest clinic if they show signs and symptoms. Refrain from sending them to child care centers, kindergartens or schools. f. Avoidance of close contact (kissing, hugging, sharing utensils, etc.) with children having HFMD illness to reduce of the risk of infection

68. MENINGOCOCCAL DISEASE

69. caused by Neisseria meningitidis ( meningococcus ) transmission: person-to-person by respiratory droplets colonization of URT  penetrate into bloodstream  go to CNS and causing meningitis (meningococcal meningitis) / infect the blood vessel (meningococcemia) Meningococcemia / meningococcal septicaemia : cutaneous signs: Maculopapular – early, often on a painful joint or pressure point Petechiae (50-70%) – distribute at trunk and extremities (can be anywhere else) Purpura (may start anywhere on the body and then spread) and necrotic area Non- cutaneous signs: altered mental status, neck stiffness, irritability, nausea, vomiting, unstable vital signs, seizure .

70. Meningococcal septicemia can kill children in hours, therefore optimal outcome requires immediate recognition, prompt resuscitation and antibiotics. Although there are now polysaccharide conjugate vaccines against groups A and C meningococcus , there is still no effective vaccines for group B meningococcus

71. History: 7 y. old boy, good general health condition Sudden onset of sore throat since 24hrs and fever at 39oC. Abdominal pain and 1 episode of vomiting No conjuntivitis,No rhinitis,No cough There is rash which look like sunburn and feel like sandpaper Strawberry tongue Attends primary school, no recent travel CLINICAL CASE

72. Scarlet Fever caused by group A streptococcus (GAS )--- transmission: direct contact through droplets Although anyone can get scarlet fever, it usually affects children between 5 and 15 years old. symptoms: rashes: develop 24 hours after the fever -can begins at below ears , neck, chest and stomach then spread all over the body within 1 to 2 days look like sunburn and feel like sandpaper more apparent at skin fold of elbow, armpit and groin area last for about 2-7 days as the rash faded, skin at the tips of lips and fingers begin to peel flush face --- fever >38.3°C------- swollen glands at the neck white or yellow spot coating on the throat and tonsil “strawberry tongue”

73. In body folds, especially the armpits and elbows, fragile blood vessels (capillaries) can rupture and cause classic red streaks called Pastia lines. These may persist for 1-2 days after the generalised rash has gone.

74. Diagnosis: 1. Throat culture remains the criterion standard for confirmation of group A streptococcal upper respiratory infection. 2.Complete blood count White blood cell (WBC) count in scarlet fever may increase to 12,000-16,000 per mm 3 , with a differential of up to 95% polymorphonuclear lymphocytes. During the second week, eosinophilia , as high as 20%, can develop. Treatment : Penicillin remains the drug of choice. Erythromycin can be considered as an alternative

75. KAWASAKI DISEASE characterized by fever at least for 5 days together with 4 of the following 5 findings: conjungtival infection mucous membrane changes (pharyngeal red, dry, cracied lips, strawberry tongue) cervical lymphadenopathy rash redness or swelling of the hands and feet, generalized skin peeling age: 4 month – 6 years cause is unknown complication: coronary artery aneurysm, sudden death

76. Complications Coronary artery aneurysm Prognosis 75% no sequelae , 25% coronary abnormality (without treatment), 1-2% mortality in the acute phase

77. Erythema infectiosum Fifth disease is a mild rash illness caused by parvovirus B19. This disease, also called erythema infectiosum , It is more common in children than adults. A person usually gets sick with fifth disease within 4 to 14 days after getting infected with parvovirus B19. Signs & Symptoms The first symptoms of fifth disease are usually mild and may include fever, runny nose, and headache. After several days, you may get a red rash on your face called "slapped cheek" This rash is the most recognized feature of fifth disease. It is more common in children than adults. Some people may get a second rash a few days later on their chest, back, buttocks, or arms and legs. The rash may be itchy, especially on the soles of the feet. It can vary in intensity and usually goes away in 7 to 10 days, but it can come and go for several weeks. As it starts to go away, it may look lacy. painful or swollen joints The joint pain usually lasts 1 to 3 weeks, but it can last for months or longer. It usually goes away without any long-term problems.

78. Complications Fifth disease is usually mild for children and adults who are otherwise healthy. But for some people fifth disease cause serious health complication. It can cause chronic anemia that requires medical treatment. Transmission Parvovirus B19—which causes fifth disease—spreads through respiratory secretions Treatment Fifth disease is usually mild and will go away on its own. Children and adults who are otherwise healthy usually recover completely. Treatment usually involves relieving symptoms, such as fever, itching, and joint pain and swelling.

79. Roseoa infantum Roseola is a common childhood infection that is caused by the same family of viruses that is responsible for chickenpox and shingles . Roseola is primarily caused by a virus called human herpesvirus 6 (HHV-6) and less frequently by human herpesvirus 7 (HHV-7). This virus can be spread by tiny droplets Roseola is generally a childhood infection, with most cases occurring before the age of 2. Roseola is a common childhood infection that is caused by the same family of viruses that is responsible for chickenpox and shingles

80. Symptoms: Fever last for 3-5 ds accompanied by malaise Fever subside after 4ds then characteristic faint, rosy-pink widespread rash that may develop. Small, flat, discoloured spots on the skin with tiny raised bumps (2 mm to 5 mm in diameter) first appear on the trunk of the body. This rash may then spread to the neck and legs, but rarely will it involve the face. This rash is neither itchy nor pus-forming and tends to whiten when pressure is applied to the reddened area. Typically, the rash will clear within a few hours, but may last up to 2 days.

81. Complication: Children: febrile convulsion Can cause meningoencephalitis , or hepatitis in adult Treatmnet : Supportive Prevention: No vaccine

82. INFECTIOUS MONONUCLEOSIS Caused by Epstein-Barr virus (EBV) Has particular tropism for B lymphocytes and epithelial cells of the pharynx Transmission usually occurs by oral contact

83. Signs and symptoms Fever Malaise Tonsillopharygitis – often severe, limiting oral ingestion of fluids and food, rarely breathing can be compromised Lymphadenopathy – prominent cervical lymph nodes Petechiae on the soft palate Splenomegaly (50%), hepatomegaly (10%) Maculopapular rash (5%)

84. DIAGNOSIS Patients with infectious mononucleosis in the differential diagnoses should have a CBC count with differential and an evaluation of the erythrocyte sedimentation rate (ESR) Because the liver is uniformly involved in EBV infectious mononucleosis, mild elevation of the serum transaminases is a constant finding in early EBV infectious mononucleosis. Heterophile antibody tests Patients with infectious mononucleosis should first be tested with a heterophile antibody test. The most commonly used is the latex agglutination assay using horse RBCs, and it is marketed as the Monospot test.

85. TREATMENT Medical Care Closely monitor patients with extreme tonsillar enlargement for airway obstruction. Steroids are indicated for impending or established airway obstruction in individuals with Epstein-Barr virus (EBV) infectious mononucleosis.   Surgical Care Surgery is necessary for spontaneous splenic rupture, which occurs in rare patients with EBV infectious mononucleosis and may be the initial manifestation of the condition.

86. REFERRENCES Evaluating the Febrile Patient with a Rash. Am Fam Physician.  2000 Aug 15;62(4):804-816 . www.slideshare.net/whiteraven68/2- fever -w- rash http:// www.merckmanuals.com/professional/dermatologic-disorders/approach-to-the-dermatologic-patient/description-of-skin-lesions http:// www.fastbleep.com/medical-notes/other/4/52/310 http://www.who.int/mediacentre/factsheets/fs286/en / http:// www.cdscoman.org/uploads/cdscoman/CDS%20Manual.pdf http:// www.cdc.gov/parvovirusb19/fifth-disease.html http:// www.medicinenet.com/roseola/article.htm http://emedicine.medscape.com/article/1132465-treatment

87. THANK YOU