Pediatrics: FEVER and RASH (Nelson Textbook of Pediatrics 21st Edition)

1. Viral Exanthems
2. Meningococcemia
3. Henoch-Schönlein Purpura
4. Toxic Shock Syndrome
5. Kawasaki Disease

1. Fever & rash PGI Jaerom Bernadas

2. TOPIC OUTLINE VIRAL EXANTHEMA Measles (Rubeola) German measles (Rubella) Roseola infantum Chickenpox (Varicella) Erythema infectiosum (Fifth disease) Hand-Foot-Mouth disease TSS MENINGOCOCCEMIA KAWASAKI HSP PITCH DECK 2

3. Viral exanthema PITCH DECK 3 Causative agent Manifestations Transmission & Communicability Management Rubeola Paramyxovirus IP: 8-12 days Rashes usually appear at the height of fever (Craniocaudal) High-grade fever, cough, conjunctivitis, colds, photophobia Koplik spots appear before the rash Airborne 4 days before & 4 days after onset of rash Supportive Vitamin A oral once daily for 2 days Diagnostic: Warthin- Finkeldey giant cells (fusion of infected cells) Rubella Togavirus IP: 14-21 days Symmetrical lymphadenopathy (begins 24H before rash & remains for 1 week) Forscheimer spots appear at the same time as rash No photophobia Fever abates on 3 rd to 4 th day as rashes appear (Centrifugal) Droplet/ Transplacental 7 days before & 6-7 days after onset of rash Supportive Diagnostic: 4x increase in IgM & IgG antibodies Roseola infantum HHV-6 & 7 IP: 9-10 days Rash appears within 12-24H of fever resolution (Centripetal) Fever for 3-5 days with fussiness Nagayama spots Bulging of anterior fontanelle Convulsions Probably acquired from saliva Supportive Diagnostic: HHV-6 serology, PCR, virus culture Low WBC count, neutrophils, lymphocytes

4. Viral exanthema PITCH DECK 4 Causative agent Manifestations Transmission & Communicability Management Chickenpox VZV IP: 10-21 days Fever then pruritic exanthem Intensely pruritic red macules, become papules, then vesicles (rapid progression) simultaneously present Direct contact/Airborne 1-2 days before onset of rash until all the lesions have crusted Oral Acyclovir best started on Day 1 of illness IV Acyclovir for severe disease and immunocompromised Diagnostic: VZV antibody titers Leukopenia at first 3 days after onset of rash followed by Lymphocytosis Fifth disease Parvovirus B19, Bocavirus IP: 4-14 days Mild fever & systemic symptoms precedes facial rash Hallmark sign: Rash with erythematous facial flushing (“slapped-cheek”) Large droplet spread/Blood-borne products Before the onset of rash until after onset of rash Supportive Diagnostic: Serum IgM antibodies PCR HFM disease Coxsackie A-16, Enterovirus-71 IP: 4-6 days 1-2 days of fever then enanthem then exanthem Tender vesicular skin lesions with surrounding erythema on the hands > feet, buttocks, groin Fecal-Oral and Respiratory Fecal shedding up to 7-11 weeks post-infection Respiratory tract shedding 1-3 weeks post-infection Supportive Diagnostic: Viral culture (Gold standard) Serotype identification for outbreaks

5. meningococcemia etiology Causative agent: Neisseria meningitidis IP: 3-4 days (range of 2-10 days) Transmission: Close contact through aerosol droplets or respiratory secretions Humans are the only natural reservoir Serogroups A,B,C,W,Y responsible for almost all cases of disease Highest rate of disease occurs in infants < 1 year old PITCH DECK 5 Risk factors Respiratory viral infections Male gender Smoking, marijuana use, binge drinking Crowded living conditions Underlying chronic disease Low socioeconomic status

6. meningococcemia PITCH DECK 6 PRESENTATION Meningococcal meningitis (30-50%) Most common presentation of invasive meningococcal infection Fever, headache, photophobia, nuchal rigidity, bulging fontanels Acute meningococcal septicemia Nonspecific symptoms (fever, altered sensorium, respiratory symptoms, vomiting, sore throat, diarrhea) Followed by cold hands/feet, abnormal skin color, prolonged capillary refill time, non-blanching petechial rash Fulminant meningococcal septicemia Rapid progression (Nonspecific to Septic shock) Prominent petechia and purpura (purpura fulminans) within hours Waterhouse- Friderichsen syndrome In fulminant cases Diffuse adrenal hemorrhage leading to adrenal failure Occult meningococcal bacteremia fever with or without associated symptoms Chronic meningococcemia Rare Fever, arthralgia, headache, splenomegaly, maculopapular or petechial rash, lasting 6-8 weeks

7. meningococcemia diagnostic Identification of meningococci from BLOOD, CSF, JOINT FLUID, or SKIN LESIONS PITCH DECK 7 management Empiric antimicrobial therapy: THIRD-GENERATION CEPHALOSPORIN DRUGS OF CHOICE: Penicillin G 300,00 U/kg/day IV in 4-6 divided doses Ceftriaxone 100mg/kg/day IM or IV 1-2x a day Cefotaxime 200-300 mg/kg/day IM or IV every 6-8 hours Treatment duration: 5-7 days

8. meningococcemia prevention Contacts during the 7 days before onset of illness should receive antibiotic prophylaxis Prophylaxis not routinely recommended for medical personnel except those with intimate exposure (intubation, suctioning, mouth-to-mouth resuscitation) Rifampicin 10mg/kg PO Q12H x 4 doses (max 600mg/dose); 5mg/kg/dose for < 1 month old < 15 yo : Ceftriaxone 125mg single dose IM >/= 15 yo : Ceftriaxone 250mg single dose IM >/= 18 yo : Ciprofloxacin 500mg PO as a single dose Meningococcal vaccine for high-risk groups: Persistent complement component deficiencies Anatomic/functional asplenia HIV Traveler/Resident of areas where meningococcal disease is hyperendemic or epidemic PITCH DECK 8

9. Henoch- Schönlein purpura Also known as iga vasculitis I mmune - complex small vessel vasculitis HSP is the most common vasculitis of childhood and is characterized by leukocytoclastic vasculitis and immunoglobulin A deposition in the small vessels in the skin, joints, gastrointestinal tract, and kidney A ffects males > females I nfectious triggers such as group A β-hemolytic streptococcus, Staphylococcus aureus, mycoplasma, and adenovirus have been suspected HSP is a disease mediated by IgA and IgA immune complexes PITCH DECK 9

10. Henoch- Schönlein purpura manifestations Hallmark of HSP is its rash: palpable purpura starting as pink macules or wheals and developing into petechiae, raised purpura, or larger ecchymoses. U sually symmetric and occur in gravity-dependent areas (lower extremities), extensor aspect of the upper extremities or on pressure points (buttocks) PITCH DECK 10

11. Henoch- Schönlein purpura manifestations Musculoskeletal: arthritis and arthralgias Gastrointestinal: abdominal pain, vomiting, diarrhea, paralytic ileus, and melena Renal: microscopic hematuria, proteinuria, hypertension, frank nephritis, nephrotic syndrome, and acute or chronic renal failure Neurologic: intracerebral hemorrhage, seizures, headaches, depressed level of consciousness, cranial or peripheral neuropathies, and behavior changes PITCH DECK 11

12. Henoch- Schönlein purpura diagnostic Diagnosis of HSP is clinical and often straightforward when the typical rash is present Palpable purpura (in absence of coagulopathy or thrombocytopenia) And 1 or more of the following: Abdominal pain (acute, diffuse, colicky pain) Arthritis or arthralgia Biopsy of affected tissue demonstrating predominant IgA deposition Renal involvement (Proteinuria > 3g/24Hr), hematuria, or red cell casts PITCH DECK 12

13. Henoch- Schönlein purpura management Treatment for mild and self-limited HSP is supportive, with an emphasis on ensuring adequate hydration, nutrition, and analgesia. Corticosteroids are most often used to treat significant GI involvement or other life-threatening manifestations Oral prednisone (1-2 mg/kg/day), or In severe cases, IV methylprednisolone for 1-2 wk , followed by taper Intravenous immune globulin (IVIG) and plasma exchange are sometimes used for severe disease PITCH DECK 13

14. TOXIC shock syndrome etiology Causative agent: Staphylococcus aureus TSST-1 act as superantigens PITCH DECK 14 manifestations Fever Diarrhea Vomiting Headache Myalgia Diffuse red macular rash that appears within 24 hours Recovery occurs within 7-10 days with desquamation especially of palms and soles

15. TOXIC shock syndrome Major criteria ALL ARE REQUIRED Abrupt onset of fever (> 38.8 C) Hypotension (Shock, Orthostatic) PITCH DECK 15 Minor criteria AT LEAST 3 Inflamed mucous membranes Vomiting, diarrhea Liver abnormalities (Bilirubin/Transaminase >2x the upper limit of N) Renal abnormalities (BUN/ Crea >2x the upper limit of N) Muscle abnormalities (Myalgia/CPK >2x the upper limit of N) CNS abnormalities Thrombocytopenia (< 100,000/mm3) exclusionary criteria Absence of another explanation Negative blood cultures (except occasionally for S. aureus )

16. TOXIC shock syndrome management Antistaphylococcal antibiotics (Oxacillin, Nafcillin, Cefazolin) + Clindamycin to decrease toxin production Consider Vancomycin where MRSA rates are very high Fluid replacement Inotropic agents Corticosteroids IVIg PITCH DECK 16

17. Kawasaki disease mucocutaneous lymph node syndrome; infantile polyarteritis nodosa Medium vessel vasculitis (Coronary and other muscular arteries) PITCH DECK 17 etiology No single infectious etiologic agent has been successfully identified

18. Kawasaki disease manifestations Fever is characteristically high spiking (≥38.3°C [101°F]), remitting, and unresponsive to antipyretics (1) bilateral nonexudative conjunctival injection with limbal sparing; (2) erythema of the oral and pharyngeal mucosa with strawberry tongue and red, cracked lips; (3) edema (induration) and erythema of the hands and feet; (4) rash of various forms (maculopapular, erythema multiforme, scarlatiniform or less often psoriatic-like, urticarial or micropustular ); (5) nonsuppurative cervical lymphadenopathy, usually unilateral, with node size >1.5 cm PITCH DECK 18

19. Kawasaki disease DIAGNOSTIC Establishing the diagnosis with prompt institution of treatment is essential to prevent potentially devastating coronary artery disease. For this reason, it is recommended that any infant age ≤6 mo with fever for ≥7 days without explanation undergo echocardiography to assess the coronary arteries PITCH DECK 19

20. Kawasaki disease Management in acute stage Intravenous immune globulin 2 g/kg over 10-12 hr and Aspirin 30-50 mg/kg/day or 80-100 mg/kg/day divided every 6 hr orally until patient is afebrile for at least 48 hr PITCH DECK 20 Management in convalescent stage Aspirin 3-5 mg/kg once daily orally until 6-8 wk after illness onset if normal coronary findings throughout course Long-Term Therapy for Patients With Coronary Abnormalities Aspirin 3-5 mg/kg once daily orally Clopidogrel 1 mg/kg/day (maximum 75 mg/day) Most experts add warfarin or low-molecular-weight heparin for those patients at particularly high risk of thrombosis Acute coronary thrombosis Prompt fibrinolytic therapy with tissue plasminogen activator or other thrombolytic agent under supervision of a pediatric cardiologist

21. Fever & rash PGI Jaerom Bernadas

22. Quiz: matching type Parvovirus B19 F Coxsackie A-16 G Intensely pruritic red macules, become papules, then vesicles (rapid progression) D Picture B PITCH DECK 22 Rubeola Rubella Roseola infantum VZV Toxic shock syndrome Erythema infectiosum HFMD

23. Quiz: matching type Nagayama spots C Picture A PITCH DECK 23 Rubeola Rubella Roseola infantum VZV Toxic shock syndrome Erythema infectiosum HFMD

24. Quiz: matching type PITCH DECK 24 Henoch- Schönlein purpura Meningococcemia Toxic shock syndrome Kawasaki disease D B A C

25. About us At Contoso, we empower hospitals to foster collaborative thinking to further support patient care and drive workplace innovation. By closing the loop and delivering wholesale medical supplies, we help hospitals grow and nurture their patients with the latest products on the market. ​ PITCH DECK 25

26. Problem Market Gap The need for medical equipment continues to be consumer driven, but we're seeing a lapse of availability in the market for wholesale medical supplies​ Costs Loss of sales by not offering wholesale medical supplies Customers 15% increase of retail sales of medical equipment proves that there's consumer interest for more wholesale availability​ Usability Customers want products that are safe and easy to stock in their hospitals​ Financials Medical equipment sales were up by $25 million in 2020 PITCH DECK 26

27. Solution Close the gap Our product makes ordering medical equipment easier​ Cost savings Reduce expenses of medical supplies by eliminating the need to buy at market value​ Target Audience Medical professionals Easy to use A simple product gives customers the information they need in order to stock their hospitals with the right equipment​ PITCH DECK 27

28. Product Overview Unique The only product specifically dedicated to the medical industry ​ Tested Conducted testing with local hospitals in the area First to market First product that’s easy to use with clear item pricing​ Authentic Designed with the help and input of medical experts in the field ​ PITCH DECK 28

29. PITCH DECK 29 Simple and efficient to use ​ Easy access to customer service ​ Quick online ordering ​ Product benefits

30. Company overview

31. Business model Research We based our research on market trends and medical supply sales ​ Abstract We believe hospitals need safe and cheap medical equipment for their patients ​ Design Simple design and easy to use  ​ PITCH DECK 31

32. Market overview $3B Opportunity to build ​ Fully inclusive market ​ Total addressable market ​ $2B Freedom to invent​ Selectively inclusive market ​ Serviceable available market ​ $1B Few competitors​ Specifically targeted market ​ Serviceable obtainable market​ PITCH DECK 32

33. Market comparison $3B Opportunity to build ​ Addressable market​ $2B Freedom to invent ​ Serviceable market​ $1B Few competitors Obtainable market​ ​ PITCH DECK 33

34. Our competition Contoso ​ Our product is priced below that of other medical supply companies on the market ​ Quick and easy to use, compared to the complex ordering system of the competitors ​ Affordability is the main draw for our hospitals to our product ​ Competitors​ Company A ​ Product is more expensive ​ Companies B & C ​ Product is expensive and inconvenient to use ​ Companies D & E ​ Product is affordable, but inconvenient to use PITCH DECK 34

35. Competition Convenient ​ A Contoso Expensive Affordable B D C E Inconvenient ​ PITCH DECK 35

36. Growth Strategy How we’ll scale in the future Feb 20xx Roll out product to hospitals in the region to help establish the product​ May 20xx Release the product to all hospitals and monitor press and regional market trends​ Oct 20xx Gather feedback from the medical staff and the healthcare community to expand availability of the product​ PITCH DECK 36

37. Two-year action plan Supply volunteers​ Run focus groups ​ Gather feedback ​ 20XX Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Test ordering ​ Regional launch ​ Deliver to hospitals ​ 20XX Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec PITCH DECK 37

38. Financials Year 1 Year 2 year 3 Income ​ ​ ​ ​ Users 50,000 ​ 400,000 ​ 1,600,000 ​ ​ Sales 500,000 ​ 4,000,000 ​ 16,000,000 ​ ​ Average price per sale ​ 75 ​ 80 ​ 90 ​ ​ Revenue @15% 5,625,000 ​ 48,000,000 ​ 216,000,000 ​ ​ Gross Profit ​ 5,625,000 ​ 48,000,000 ​ 216,000,000 ​ ​ Expenses ​ ​ ​ ​ ​ Sales & Marketing ​ 5,062,500 ​ 38,400,000 ​ 151,200,000 ​ 70% ​ Customer Service ​ 1,687,500 ​ 9,600,000 ​ 21,600,000 ​ 10% ​ Product Development ​ 562,500 ​ 2,400,000 ​ 10,800,000 ​ 5% ​ Research ​ 281,250 ​ 2,400,000 ​ 4,320,000 ​ 2% ​ Total Expenses ​ 7,593,750 ​ 52,800,000 ​ 187,920,000 ​ PITCH DECK 38

39. Meet the team Takuma Hayashi​​ President​ Mirjam Nilsson​​ Chief Executive Officer​ Flora Berggren​​ Chief Operations Officer​ Rajesh Santoshi​​ VP Marketing​ PITCH DECK 39

40. The full team Takuma Hayashi​ President​ Graham Barnes​ VP Product​ Mirjam Nilsson​​ Chief Executive Officer​ Rowan Murphy​ SEO Strategist​ Flora Berggren​​ Chief Operations Officer​ Elizabeth Moore​ Product Designer​ Rajesh Santoshi​​ VP Marketing​ Robin Kline​ Content Developer​ PITCH DECK 40

41. Summary At Contoso, we believe in giving 110%. By closing the loop and delivering wholesale medical supplies, we help hospitals grow and nurture their patients with the latest healthcare products. We thrive because of our market knowledge and a great team behind our product. As our CEO says, "Efficiencies will come from proactively transforming how we do business."​ PITCH DECK 41

42. PITCH DECK 42 Mirjam Nilsson​​ 206-555-0146​ [email protected]​ www.contoso.com​ Thank you