Fever with rashes, decribing various types of fever presenting with rash

Fever with rashes presentation

1. FEVER WITH RASHES
Roll number 31-36

2. FEVER WITH RASHES
►Fever with rash is a common and vexing problem.
►Macular or Maculopapular rash
►Common: Measles, rubella, dengue, roseola infantum, erythema infectiosum, drug rash,
adenoviral or enteroviral infections Less common: Infectious mononucleosis,
chikungunya, HIV,
►Mycoplasma pneumoniae, secondary syphilis, brucellosis, scrub typhus, chronic
hepatitis B, cytomegalovirus, lupus, systemic onset juvenile rheumatoid arthritis
►Diffuse erythema with peeling or desquamation
►Common: Stevens-Johnson syndrome, drug induced toxic epidermolysis, Kawasaki
disease
►Less common: Scarlet fever, staphylococcal and streptococcal toxic shock syndrome
►Vesicular rash
►Common: Chickenpox, enteroviral infections (hand-foot-mouth disease)
►Less common: Herpes simplex, herpes zoster, papulonecrotic tuberculosis

3. ►Petechial and/or Purpuric rash
►Common: Meningococcemia, dengue hemorrhagic fever, Henoch-Schonlein
purpura
►Less common: Indian spotted fever, gonococcemia, hemorrhagic measles,
chickenpox, cutaneous vasculitis
►Urticaria! rash
►Common: Scabies, insect bites
►Less common: Cutaneous larva migrans due to hookworm,
►strongyloides, pediculosis
►Nodular rash
►Common: Erythema nodosum due to tuberculosis, drugs, sarcoid, inflammatory
bowel disease, lepromatous leprosy; Molluscum contagiosum
►Less common: Disseminated histoplasmosis, cryptococcosis

4. EVALUATION
►The nature of the rash often provides clues to determine the etiology of the exanthematous
febrile illness.
►Rashes may be macular, maculopapular, vesicular, nodular, urticaria! or purpuric.
►Other factors that assist in diagnosis include epidemiological factors, season, history of
exposure, incubation period, age, vaccination status, previous exantherns, prodromal
symptoms, relation of rash with fever, distribution and progression of the rash, involvement of
mucous membranes, drug intake and associated symptoms.
►Examination should include nature of the rash and its distribution, involvement of palms and
soles (seen with dengue, spotted fever, Kawasaki disease and Stevens Johnson syndrome),
involvement of mucous membranes, lymphadenopathy, organomegaly.

5. MANAGEMENT
►Symptomatic therapy, close observation, explanation of
danger signs to parents and staying away from school
until the rash resolves, is recommended.

11. MEASLES (RUBEOLA) VIRUS 
• Measles is an acute, highly contagious childhood disease characterized by fever & respiratory symptoms,
followed by typical maculopapular rash.
Pathogenesis 
Transmission :Droplets inhalation over short distances less commonly-Small-particle aerosols
that remain suspended especially in schools, hospitals, and enclosed public places in the air for
longer period.
 Spread-The virus multiplies locally in the respiratory tract; then spreads to the regional lymph
nodes → enter into the bloodstream in infected monocytes (primary viremia)→further multiply
in reticuloendothelial system → spills over into blood (secondary viremia)→disseminate to
various sites. 
Target sites : The virus is predominantly seeded in the epithelial surfaces of the body,
including the skin, respiratory tract, and conjunctiva

12. Clinical Manifestations 
 Incubation period is about 10days which may be shorter in infants and longer (up to 3
weeks) in adults.
 Disease can be divided into three stages.(Prodromal stage, Eruptive stage, Post
measles stage).
 Prodromal stage: Lasts for four days (i.e. from 10th to 14th day of infection) Fever,
Koplik’s spots, Non-specific symptoms.
 Eruptive stage: Maculopapular dusky red rashes. Rashes typically appear first
behind the ears→then spread to face, arm, trunk and legs→then fade in the same
order after four days of onset .
Fever (10th day)→ Koplik’s spot (12th day) → rash(14th day) 
Post measles stage- It is characterized by weight loss and weakness. There may be
failure to recover and gradual deterioration into chronic illness.

13. Koplik spot in buccal
mucosa (measles) 
Measles rashes (on face)
Multinucleated giant
cell of measles infected
cell lines 

14. Complications 
•  Complications result from secondary bacterial infections: Otitis media and
bronchopneumonia are most common 
Recurrence of fever or failure of fever to subside with the rash
 Worsening of underlying tuberculosis with a false positive Mantoux test
Complications due to measles virus itself Giant-cell pneumonitis -
immunocompromised children, HIV infected people Acute laryngotracheobronchitis
 Diarrhoea, leads to malnutrition including vitamin A deficiency Complications
CNS complications Post-measles encephalomyelitis Measles inclusion body encephalitis
Subacute sclerosing panencephalitis (SSPE)

15. Live attenuated Measles vaccine 
 Schwartz strain (currently serves as the standard in much of the world)
 Edmonston-Zagrebstrain
 Moraten strain
 Vaccine is prepared in- chick embryo cell line
Reconstitution- Vaccine is available in lyophilized form and it has to be reconstituted with
distilled water and then should be used within 4 hours.
 Vaccine is thermolabile- must be stored at -20 0C.
One dose (0.5ml) containing >1000 infective viral units is administered subcutaneously. 
• Side effects include- Mild measles like illness, toxic shock syndrome 
Contacts- Susceptible contacts over 9-12months may be protected against measles if the
measles vaccine is given within 3 days of exposure

16. RUBELLA
►Rubella produces childhood exanthema similar to measles. Therefore rubella is also
called as German measles.
►Rubella is highly teratogenic; can cause congenital rubella syndrome.
►It contains ssRNA, surrounded by a capsid protein and an envelope.
►There is only one serotype and humans are its only known reservoirs.
►Rubella may present in two clinical forms: Postnatal infection and Congenital
Infection

17. 1.Postnatal Rubella
►Postnatal rubella may occur during neonatal age, childhood and adult life.
►TRANSMISSION: Spreads from person to person by respiratory droplets via upper respiratory mucosa.
►SPREAD: It replicates locally in the nasopharynx and spreads to lymph nodes.Subsequently viremia develops
after 7-9 days and last until 14
th
day by which time both antibody and rashes appear simultaneously
suggesting an immunological basis.
►CLINICAL MANIFESTATIONS:
Incubation period- 14days
Rashes are often first to appear in children.They are generalized and maculopapular in nature, start on
face,extend to trunk and extremities and disappear in 3 days.
Lymphadenopathy is the most striking feature.
Forscheimer spots- Pin Head sized Petechiae develop in soft palate
and uvula.
►COMPLICTIONS:Arthralgia and Arthritis common in adults.

18. 2.Congenital Rubella Syndrome
►Highly teratogenic;affects ear(deafness),eye (cataract),heart (patent ductus arteriosus)
►Once infected person acquires lifelong immunity.
►Period of communicability is 1 week before to 1 week after appearance of rash.
►Transmission is by air droplets,transplacental.
Prevention of Rubella:
Rubella vaccine-RA 27/3 is a live attenuated vaccine,prepared from human diploid fibroblast cell line.
Available singly or in combination with vaccines of mumps and measles.
Schedule: single dose 0.5 ml given subcutaneously.Under national immunizations schedule given at 9-12
months(MR) and Second dose 16-24 months of age in some states.
Indicated for all women of reproductive age group followed by children (till 14yrs)
Vaccine contraindicated in pregnancy since teratogenio.Pregnancy to be avoided atleast till 4 weeks after
vaccination.
Infants below 1 yr should not be vaccinated due to possible interference from persisting maternal
antibody

19. Herpes Simplex Virus
The causative organism:
►Herpes Simplex Viruses (HSV-1& HSV-2) belongs to the
family alpha Herpesviridae
►They are large and encapsulated with an icosahedral
nuclear capsid arranged around a linear double stranded
DNA core
►Humans are the natural hosts of both HSV-1 and HSV-2

20. HSV-2
►Virus infects sites below the waist
►Transmission: Primarily by sexual contact
Clinical findings
►Herpes genitalis
►Neonatal encephalitis
►Aseptic Meningitis
HSV-1
◦Virus infects sites above the waist
◦Transmission: Primarily through saliva
Clinical findings:
◦ Acute gingivostomatitis
◦Recurrent herpes labialis
◦Keratoconjunctivitis
◦Encephalitis

21. Neonatal Herpes
►HSV infection in a neonate is uncommon with an incidence of 1 in 3200 deliveries.
►However, compared with other infections like syphilis, rubella, toxoplasmosis, its incidence
is higher.
►Originates chie?y form contact with vesicular lesions within the birth canal
►Neither HSV-1 or HSV-2 causes congenital abnormalities to any signi?cant degree

22. Transmission
►Usually occurs in mothers who develop primary genital herpes at the time of delivery.
►Reactivation of genital herpes is associated with very low rates of transmission and foetal a?ection
►Infected babies may be asymptomatic or have fulminant disease
►Factors influencing: (a) type of maternal infection (primary/secondary )
(b) maternal antibody status
(c) mode of delivery – caesarian has lower incidence
(d) duration of rupture of membrane – longer duration increases chances
(e) type of HSV(1 or 2) –higher incidence of transmission of HSV 1

23. Types
►A vesicular eruption limited to skin, eyes and
mouth,
►CNS disease presenting as meningitis with
seizures and altered sensorium
►Disseminated disease presenting as sepsis like
illness, respiratory failure, hepatic failure, DIC
►Mortality rate is higher in disseminated than
CNS
►Disabilities of chronic duration is more in CNS
and less in disseminated

24. Diagnosis & Treatment
►Diagnosis is by Tzanck smear of the skin lesions, culture or PCR for the virus from lesions or
from CSF.
►HSV serology has no role in making diagnosis
►Treatment with intravenous acyclovir should be started promptly in neonates with suspected
or con?rmed infection.
► Babies born to mothers with active herpetic lesions during delivery should be watched
carefully for disease.
►Elective cesarean section should be considered in mothers with active primary genital herpes
and unruptured membranes

25. BODY TEMPERATURE
►The normal body temperature in children is higher compared to adults - 36.1 - 37.8°C.
►Children also shor diurnal variation in their body temperature. It is highest between 5-7PM and
lowest 12-6AM
►It can be measured over many sites including - oral cavity, ear canal, temporal artery.

26. ASSOCIATED RASH
Fever with rash is a common problem whhich may
indicate a serious desorder (like Dengue Hemorrha
-ic Fever,) or a minor drug allergy.
RASH INCLUDES :
Macular, Vesicular, Maculopappular, Nodular,
Urticarial, Purpuric dermatic lesions.

27. EBV
Infectious mononucliosis (IM) -
Syndrome characterised by fever, fatigue,
sore throat and lymphadenopathy.
It is caused by EBV. IM-like condition is
caused by toxoplasma, CMV, adenovirus and
1° HIV infection.

28. Differential diagnosis -
Streptococcal pharyngitis, Acute lukemia
Treatment -
Rest, symptomatic therapy
Strain to be avoided due to risk of splenic
rupture.
Prednisolone and intranasal steriods given.
Acyclovir used in immunocomprimised
patients.

29. CMV (HSV-5)
►Congenital -
All organ systems are affected.
Characteristic feature:-
# Periventricular calcification,.
# Owl eye appearance
Increased risk at initial pregnancy.
►Perinatal CMV :- During delivery
Interstitial pneumonitis

30. ►Immunocomprimised - Severe infection.
Latent virus reactivation is seen
► Complications:- Bilateral interstitial pneumonia
febrile leucoplakia
Obliterative broncholotis
Graft atherosclerosis.
►Treatment:-
Gancyclovir DOC
Adjuvant:- valgancyclovir