Approach to rash in child_handout
Approach to rash in child_handout
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 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
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
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
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
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
Krugman 2004
Roseola Infantum
B 20
Pathognomonic / diagnostic sign / Laboratory test
• Measles
• Koplik’s spot
• Rubella
• Post auricular and occipital lymphadenopathy
• Serological test
• Morbili
• Rubella
• Toxoplasmosis
• Enterovirus etc
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