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0% found this document useful (0 votes)
21 views65 pages

Approach to rash in child_handout

Uploaded by

rsmitrahuada
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Approach to rash in child:

is it just a viral infection?

Mulya Rahma Karyanti, MD, M.Sc, Ph.D

Department of Child Health


Medical School, University of Indonesia, Jakarta
Outlines
• Introduction
• Etiology
• Classification
• Diagnosis establishment & algorithms
• Management
• Take home message
Introduction
• The causes of fever with rashes vary widely, ranging from
mild to severe and even life-threatening if not treated
immediately
• Error in diagnosis may have a profound => mismanagement:
• Effect on the patient
• Effect on contacts
• Effect on community
Often presents a diagnostic challenge
Rubella Scarlet fever

Etiology viral or bacterial???


Etiology
Infection
• Viruses Allergic
• Bacterial reaction
• Others

Autoimmune
Malignancies
process
Infection and rash
• Fever with exanthems ➔ disease that manifested as:
• Fever
• Diffuse skin eruption
• Related with systemic infection
• Commonly caused by virus infection
• Pathogenesis of rash :
• Pathogen invasion
• Multiplication and toxin production
• Immunity host responds
Clinical approach fever with rash in children
History taking
• Prior infectious diseases • Contacts
• History of fever, pattern of fever • Age
• When rash appear? Relationship • Season
with fever? • Exposure to toxins or
• Pattern of evolution of the rash medications
• Associated symptoms and signs • Exposure to an ill person
• Immunisations history • Geographic location and travel
• Travel • History of previous illness
• Prodromal illness • Exposure to domestic or wild
animals
Physical examination
General state • Temperature
• Is the patient well enough to be • Conjuctiva
evaluated on as outpatient setting or
needs hospitalization? • Ears and throat
• If admission is required, is the • Auscultation of chest
patient's life threatened from the
disease and an urgent medical • Abdomen – liver and spleen
intervention required?
• Lymph nodes
• Is there the risk of transmission to
others and warranted precaution and
isolation?
• Does the disease acquire notification
from the public health point of view?
Classification
Fever with rashes as symptoms of serious illness and requires
immediate treatment
• meningococcemia, Kawasaki disease, Dengue hemmorhagic fever, Rocky
mountain spotted fever

Fever with rashes that shows typical symptoms for certain


infectious diseases: mild & often does not need special therapy
• measles, roseola infantum, eritema infeksiosum, varisela, HFMD

Fever with rashes that appears early in the disease and does not
clearly lead to a particular disease
GENERAL APPROACH TO CLINICAL DIAGNOSIS OF INFECTIONAL
DISEASES WITH MANIFESTATIONS OF FEVER AND RASH
RASH
- Onset: sudden or gradual
- Type
- Distribution: central, peripheral, generalized
- Progression: direction of spread, speed of progression
- Symptoms: itch, pain, burning
- Relationship of rash to fever

General well-being of the child, including prodromal illness or fever


GENERAL APPROACH TO CLINICAL DIAGNOSIS OF INFECTIONAL
DISEASES WITH MANIFESTATIONS OF FEVER AND RASH
BE SURE TO EXAMINE
Degree of toxicity
The entire skin surface
The mucous membrane involvement or ulceration

12
GENERAL APPROACH TO CLINICAL DIAGNOSIS OF INFECTIONAL
DISEASES WITH MANIFESTATIONS OF FEVER AND RASH

32
Exanthemas
Determination of the relationship between
fever, rash and other clinical symptoms
• What is the shape and type of rash?
• When and where the rash started?
• Has the rash progressed to other parts of the body
• What is the relationship between fever and rash
• Has the rash changed morphologically?
• Were there any other signs/ symptoms before the rash erupted?
• Has treatment begun for the patient?
Risk infection transmitting to others
R0 is affected by mode of transmission
• Measles Diseases Transmission R0
• Varicella Measles Airborne 12-18
Varicella Contact, Airborne 10-12
• Rubella
Rubella Airborne, droplet 5-7
• Scarlet fever Scarlet fever Droplet, Contact 5-8
• Meningococcemia Meningococcal Droplet
HFMD Airborne, droplet 15.8–30.1
• Hand foot mouth diseases
R0 = disease’s basic reproduction number,
which represent expected number of new
cases that might be generated from one
infection case
Progress to severe and life-threatening
• Meningococcemia
• Measles
• Kawasaki disease
• Dengue infection
Referred immediately
• Severe dengue
• Meningococcemia
• Kawasaki
• Measles with complications
• Varicella in immunocompromise
• HFMD with central nervous system complication
• MIS-C

DON’T MISS THE RASH !


Rash characteristic
• Distribution
localized
generalized progressive

MONKEYPOX

MEASLES
HERPEZ ZOSTER
Rash distribution
DENGUE VIRUS INFECTION
• Etiology: Dengue virus
• Transmission: Aedes mosquitos as vector
• Vector:
• Aedes aegypti
• Aedes albopictus
• Incubation period: 1 week
DENGUE VIRUS INFECTION
• 8 Clinical Spectrum (Guideline 2011)
• Severe Dengue:
• Severe plasma leakage
• Severe bleeding
• Organ dysfunction
• Definitive diagnosis: virus isolation, virus culture, PCR,
NS1, IgM, IgG
• Treatment: Symptomatic-Supportive, the main
treatment → Fluid management
MENINGOCOCCEMIA
• Etiology: Nisseria meningitidis: Serotype A, B, C,
W135, Y
• Transmission: Droplet
• Incubation: 1-10 days
• Definitive diagnosis: culture, PCR, NS1, IgM, IgG
• Main clinical symptoms:
• Sepsis
• Meningitis
MENINGOCOCCEMIA
• Clinical symptoms
• Sepsis symptoms, such as:
• high fever, chills, restlessness, anxiety, lethargy,
malaise
• Headache, nausea, vomitus, myalgia, arthralgia,
abdominal pain
• Extensive Purpura Fulminans (PF)
• Shock
• Comma
MENINGOCOCCEMIA

- Masa prodromal berupa nyeri N. meningitidis - Ruam kemerahan+ petekie


tenggorokan diikuti demam (gr - ) 24jam makulapapular
tinggi, nausea dan diare dan purpura seluruh tubuh
- Kaku kuduk +/- - Membran mukosa JARANG
Identifikasi kuman :
- Predileksi khusus (-)
- Pewarnaan gram
- Kultur darah, lesi
kulit, LCS

Javid MH. Meningococcemia. Medscape; Updated September 15,2021


MENINGOCOCCEMIA
• Exanthema: Petechiae-purpura-ecchymosis; may
involve from macule-papule
• Enanthema: mucosal bleeding
• Definitive diagnosis: culture, PCR, gram stain
• Prognosis: can get worse to severe
meningococcemia and quickly bring to death
MENINGOCOCCEMIA
• Complications: Myocarditis, sepsis, extensive
bleeding, DIC, shock, gangrene, comma
• Treatment: Ceftriaxone, Cefotaxime, Penicillin G
• Prevention:
• Immunization: B and A-C-W-Y
• Rifampicin, Ciprofloxacin, Ceftriaxone,
Azithromycin
KAWASAKI DISEASE
• Etiology: unknown
• Transmission: none
• The most common age: 1-2 years
• Incubation period: unknown
• Definitive diagnosis: None
• Clinical diagnosis: persistent high fever plus at
least 4 other signs/symptoms
KAWASAKI DISEASE
• Clinical Manifestations:
• Persistent high fever
• Rash-maculopapular
• Cervical node enlargement
• Conjunctivitis
• Edema and erythema on palmar and plantar
• Clinical diagnosis: Persistent high fever plus at least 4 other
signs/symptoms
• Peeling of the fingertips and around anal skin
KAWASAKI DISEASE
Exanthema:
• Maculopapular from the head, trunk, and spread to extremities, can
involve vesicles
• Non pruritic erythemal rash
• Widespread polymorphic rash (erythema multiforme)

Enanthema
• Oral and pharyngeal mucosa
• Strawberry tongue
• Erythema and crackles of lips (cheilitis)
• Conjunctivitis
mucocutaneous lymphnode syndrome
Penyakit Kawasaki
Kriteria diagnostik untuk penyakit Kawasaki
1. Demam remiten, bisa mencapai 41º C dan
berlangsung > 5 hari
2. Injeksi konjungtiva bilateral (tanpa eksudat)
3. Kelainan di mulut dan bibir : lidah stroberi, rongga
mulut merah difus, bibir merah dan pecah.
4. Kelainan tangan dan kaki : eritema dan edema pada
- Penyakit inflamasi pada dinding
fase akut, serta deskuamasi ujung jari tangan dan kaki
pembuluh darah di seluruh tubuh
- Juga mengenai KGB,kulit dan pada fase subakut.
mukosa mulut dan bibir 5. Eksantema makulopapular, polimorfik, generalisata
- Mengenai balita 6. Limfadenopati servikal unilateral (diameter >1,5 cm)
Laboratorium tidak spesifik
- Anemia,hipoalbuminemia (fase akut)
- Kenaikan LED,lekosit,netrofil,CRP
- Trombositosis (fase subakut)

Self limiting
Komplikasi :
kelainan jantung
progresif Scheinfeld NS. Kawasaki disease clinical presentation. Medscape; Upload July 29, 2018
Scheinfeld NS. Kawasaki disease clinical presentation. Medscape; Upload July 29, 2018
KAWASAKI DISEASE
• Laboratory findings or additional examinations:
• CRP
• LED
• Thrombocytosis
• Anemia
• Treatment:
• Immunoglobulin
• Aspirin
KAWASAKI DISEASE
• Complications:
• Aneurysm of coronary artery
• Keratitis, uveitis
• Urethritis
• Meningitis
• Liver dysfunction
MEASLES WITH COMPLICATIONS
Exanthema:
• Maculopapular from the head and neck, spread to
trunk and extremities
• Ended by hiperpigmentation

Enanthema
• Koplik spots → white granules like sand on buccal
premolar I
Kasus2 campak dari 1 rumah singgah
MEASLES WITH COMPLICATIONS
• Definitive diagnosis: virus isolation, IgM urine
• Treatment: isolation, vitamin A, supportive,
symptomatic
• Complications:
• Diarrhea
• Pneumonia
• Otitis media
• Febrile seizures
• Hepatitis
MEASLES WITH COMPLICATIONS
Prevention:
• Immunization: measles, MR, MMR,
MMRV
• Isolation
• Avoid contact
• Immunoglobulin
VARICELLA IN IMMUNOCOMPRISE
• Etiology: Varicella Zoster Virus (VZV)
• Transmission: droplet
• Incubation period: 1-3 weeks before the rash
appear
• Clinical manifestations:
• Subfebrile
• Cough, coryza
• Maculopapular eruption → turns into vesicle
→ ended with crust
VARICELLA IN IMMUNOCOMPRISE
Exanthema:
• Vesicles or blisters from the head, trunk, and spread to extremities
• Thin gray vesicle walls surrounded by a halo
• Can be found at different ages
• Itchy (pruritic sensations)
• Ended with crust, and peeled itself off, without leaving any marks

Enanthema
• Oral and genital vesicles and ulcers
• Congestion of conjunctiva
VARICELLA IN IMMUNOCOMPRISE
• Definitive diagnosis: virus isolation, PCR, IgM
• Complications:
- Secondary infection of the skin
- Ataxia, meningoencephalitis
- Pneumonia
- Keratoconjunctivitis, hepatitis, arthritis,
myocarditis
VARICELLA IN IMMUNOCOMPRISE
• Treatment:
• Acyclovir – Valacyclovir
• Supportive, symptomatic

• Prevention:
• Immunization
• Isolation, avoid contact
• Immunoglobulin
VARICELLA IN IMMUNOCOMPRISE
• Immunocompromised:
• HIV
• Steroid use
• Malignancy
• Neonates → varicella neonatal

• High risk of getting worse


• Lesions widespread quickly, and can be in pustule form or
extensive bleeding
• Complication easily appear
• Treatment: intravenous acyclovir
• Immunoglobulin needed in several conditions
HFMD WITH CNS COMPLICATIONS
• Etiology: Enterovirus 71, Coxsackie A16
• Transmissions: droplet
• Incubation period: 3-6 days
• Clinical manifestations:
• Subfebrile
• Throat pain, dysphagia
• Rash → vesicle, itchy
• Definitive diagnosis: virus isolation, PCR
HFMD WITH CNS COMPLICATIONS
Exanthema:
• Lesion starts from the maculopapular and can be vesicles
• Extremities & gluteus, palmar & plantar
• Perioral rash

Enanthema
• Painful vesicles and ulcers in buccal, labial, genital
Multisystem inflammatory syndrome in children
(MIS-C)

Pedoman PP IDAI
CONGENITAL RUBELLA SYNDROME
• Etiology: Rubella Virus
• Transmissions: Vertical transmission (from mother to
child in womb)
• Clinical manifestations:
• Eyes
• Ears
• Heart
• CNS
• Definitive diagnosis: virus isolation, PCR, IgM
CONGENITAL RUBELLA SYNDROME
• There’s a national surveillance program
• Treatment: supportive and symptomatic
• Prevention: Immunize adolescent girls and
mothers with immunization
• Screening: not required
Prodromal period (1)
• Measles
• Rash preceded by 3-4 days of fever, conjunctivitis,
coryza and cough
• Rubella
• Usually no prodromal period in children
• Adolescents may have 1-2 days malaise and low fever
• Scarlet fever
• Fever 12 hrs, sore throat and vomiting
• Meningococcemia
• Fever, vomiting, irritability, chills, headache in 24 hrs
Prodromal period (2)
• Roseola infantum
• High fever for 3-4 days and irritability
• Kawasaki disease
• Non specific fever and sore throat for 2-5 days
• Varicella
• Usually absent,
• in adolescent maybe 1-2 days fever, headache,
malaise and anorexia
• HFMD – hand, foot and mouth disease
• Flu like syndrome for 1-3 days
Natural history of the diseases
Measles Rubella

Scarlet fever Roseola infantum

Krugman 2004
Roseola Infantum

Roseola infantum. (A)


Erythematous, blanchable
macules and papules in an
infant who had a high
fever for 3 days preceding
the skin eruption. (B) On
closer inspection, some
lesions reveal a subtle
peripheral halo of
vasoconstriction.

B 20
Pathognomonic / diagnostic sign / Laboratory test
• Measles
• Koplik’s spot
• Rubella
• Post auricular and occipital lymphadenopathy
• Serological test
• Morbili
• Rubella
• Toxoplasmosis
• Enterovirus etc

Courtesy of Alan R. Tumbelaka


Drug eruptions

Alan R Tumbelaka
Take home messages
• To establish diagnosis of the acute exanthems or fever with rashes is
based on a number of factors, including:
• The past history of infectious disease and immunization
• Features of the rash
• Presence of pathognomonic or other diagnostic signs
• Laboratory diagnostic tests
• The character and duration of the prodromal period are also important
• In certain diseases the prodrome is characterized by respiratory tract
symptoms; in others, influenza-like symptoms predominate
• Generally, fever with rashes are caused by viral infection and self-
limited but some are life threatening and need specific treatment
THANK YOU

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