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FEVER and RASH

FEVER and RASH. Yinghu Chen Dept. Infection Disease Email: Chenyinghu @ sina .c o m. Pediatrics. Rash and infections. Rashes are a common manifestation of many infections. Skin lesions provide important clues to the diagnosis Macular or Maculopapular Rash Diffuse Erythroderma

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FEVER and RASH

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  1. FEVER and RASH YinghuChen Dept. Infection Disease Email: Chenyinghu@sina.com Pediatrics

  2. Rash and infections Rashes are a common manifestation of many infections. Skin lesions provide important clues to the diagnosis Macular or Maculopapular Rash Diffuse Erythroderma Urticarial Rash Vesicular, Bullous, Pustular Petechial-Purpuric Erythema Nodosum

  3. Differential Diagnosis of Fever and Rash Macular or Maculopapular Rash -- virus Measles Rubella Roseola (HHV-6 or HHV-7) Varicella-Zoster virus (VZV)

  4. Differential Diagnosis of Fever and Rash Macular or Maculopapular Rash--bacteria Scarlet fever (group A streptococcus) Others: Secondary syphilis, Leptospirosis,  Pseudomonas, Meningococcal infection (early), Salmonella typhi (typhoid fever), Lyme disease (erythema migrans), Mycoplasma pneumoniae

  5. Measles

  6. Outline Etiology Epidemiology Pathogenesis Clinical manifestations Lab findings Treatment Complications Preventions

  7. Introduction Historically widespread but now very rare Characterized by fever, coryza, cough, Koplik’s spots, and maculopapular rash

  8. Etiology Measles virus, a single-stranded RNA paramyxovirus with one serum type. Humans are the only natural host Found in nasopharyngeal secretions, blood and urine, during the prodromal period and for a short time after the rash appears Remain active for 1-2 days at room temperature

  9. Epidemiology Spread throughout the world, vaccine-preventable disease For susceptible persons, 90% of the exposed acquire disease Infection sources: patients and person with latent infection Contagious period: 5 days before and after the rash appearance, accompanied with pneumonia, prolonging to 10th day Transmission: airborne and contact Season: spring, Age: 5-10yr New trends: measles appears in <8m infants and elders, due to inadequate vaccination as well as vaccine failure

  10. Pathogenesis Process of virus in the body (two times of viremia) Invade airway endothelial cells, portal lymph node, and multiply (warthin-Finkeldey giant cell) Some invade to blood Captured by Monocyte - macrophage system, and replicates greatly, Invade blood second time, cause disseminated lesions, some target T cells The host immunity decrease, induce secondary bacterial infection and TB reactivation Endothelial cells Dendritic cell T cells

  11. Pathogenesis

  12. Clinical manifestaions Persons with typical symptoms immunocompetent children who didn’t receive measles vaccine, or vaccine failure, and didn’t receive immunoglobulin Four stages Incubation stage: 6-12d, may transmit virus by 9-10th day Prodromal stage: 3-5d, fever, cough, coryza, Koplik spots Rash stage: rash erupts for 2-3d , and fades Recovery stage

  13. Prodromal stage Last 3-5d, low-grade to moderate fever, dry cough, coryza, and conjunctivitis, photophobia, Koplik spots.

  14. Koplik spots and Stimson line Koplik spots: 1-2d before rash, grayish white dots, as small as grains, opposite the lower molars, may spread over the buccal mucosa, last 12-24hr

  15. Rash stage Temperature rises abruptly as the rash appears and often reaches 40℃ or higher The rash appears and fade downward sequence: stars (faint macules) on the upper lateral part of neck, behind the ears, along the hairline, cheek, spreads to entire face (maculopapular), neck, upper arms, chest back, abdomen, entire arm, thighs, and finally reach feet on the 2nd-3rd day In uncomplicated cases, as the rash appears on the legs and feet, the patients may appear desperately ill, but the symptoms subside within 2d Branny desquamation within 7-10d

  16. Black measles Hemorrhagic type of measles Bleeding may occur from mouth, nose, or bowel, thrombocytopenia Occurs in immunocompromised or secondly infection patients Rash is confluent, petechiae Often accompanied with pneumonia, heart failure, disseminated intravascular coagulation (DIC), high mortality

  17. Mild measles Mild cases Occurs in person with partial protection against measles, such as vaccine, immuoglobulin

  18. Atypical measles • Partial protection against measles, such as vaccine. • Fever 2-3 days,appearance of the rash. • The eruption order: the distal limbs, trunk and face. • Mild case.

  19. Laboratory findings Cytopathic change Warthin-Finkeldey cells: consist of multinucleated giant cells with intranuclear inclusions Antigen: in nasal mucosa PCR Virus isolation Antibodies IgM and IgG become detectable when the rash appears Leucocytopenia with a relative lymphocytosis

  20. Chest radiograph May show interstitial or perihilar infiltrates, but do not distinguish measles pneumonia and bacterial superinfection.

  21. Diagnosis Contact history Characteristic clinical picture Laboratory confirmation is rarely needed

  22. Differential diagnosis All kind of fever with red rashes Such as: Rubella, roseola, scarlet fever, meningococcemia, drug fever, Kawasaki disease, serum sickness, infectious mononucleosis, toxoplasmosis, etc

  23. Differential diagnosis Enteroviral and adenoviral infections, rubella: The rashes are less striking without desquamation Roseola infantum: the rash appears as fever disappears Serum illness and drug fever: The absence of administration of a drug history

  24. Red rash in bacterium infection Acute meningococcemia The rash is petechial, and purpuric without cough and conjunctivitis Streptococcal scarlet fever The diffuse, finely papular rash has a “goose flesh” texture, “sandpaper” texture, strawberry tongue, red pharynx. Perioral and periorbital area, palm, and soles have no rash. Rash desquamates after 7-14d Staphylococcal scarlet fever Resembles streptococcal scarlet fever Except strawberry tongue, pharynx, and focal infection usually presents

  25. Treatment No specific antiviral therapy Supportive treatment: antipyratic, bed rest, fluid intake, avoiding exposure to strong lights Vitamin A: 7-12m infant: 100,000IU, ≥1y: 200,000IU, reduce the morbidity and mortality Complications such as encephalitis, giant cell pneumonia, DIC must be assessed individually Secondary infection requires antimicrobial therapy Immune globulin and corticosteroids has limited value

  26. Vitamin A and measles: evidence Hyporetinemia is present in over 90% of measles cases in Africa and 22-70% in USA. There is an apparent inverse correlation between retinol concentration and the severity of measles. Oral Vitamin A supplement reduces the morbidity and mortality of severe cases.

  27. Indication for Vit A supplement(American Academy of Pediatrics) Hospitalized children 6mo~2yr of ages Children >6mo with immunodeficiency ophthalmologic evidence of Vit A deficiency impaired intestinal absorption moderate to severe malnutrition recent immigration from areas with a high mortality from measles

  28. Complication Pneumonia Interstitial pneumonia: may be caused by measles virus (giant cell pneumonia), measles pneumonia in HIV-infected patients is often fatal. However, bacterial superinfection and bronchopneumonia is more frequent Reactivation of TB infection, and anergy to PPD Myocarditis An infrequent serious complication, varies from transient electrocardiographic changes to heart failure, and cardiogenic shock

  29. Complication in nervous system Eary encephalitis 1-2/1000 cases, occur from prodromal period to final stage Late encephalitis Demyelinization, probably an immunopathologic phenomenon. Subacute sclerosing panencephalitis (SSPE) A chronic encephalitis caused by persistant measles virus infection of the central nervous system, occur 8-10yr after measles Insidiously onset, subtle changes in behavior, and deterioration of schoolwork, and finally dementia. 1/1,000,000 measle

  30. Prognosis Deaths: bronchopneumonia or encephalitis(15%), with malignancy or HIV infection SSPE

  31. Prevent Attenuate live measle vaccine Two times(8m, 4-6yr), not booster, but intensive immunization Contraindications: Immunocompromised states, pregnancy or recent administration of IVIg

  32. Postexposure prophylaxis Vaccine within 72 hr (produce antibody within 7-12d) Immune globulin within 6d

  33. Typical temperature curve of measles and the effectiveness of passive immunization

  34. Take home points Koplik spots Feature of measles maculopapular rash Differential diagnosis of red rash Complications Post exposure prophylaxis

  35. Rubella

  36. Rubella also known as German measles and 3-day measles; congenital rubella syndrome (infection in utero )

  37. Etiology and epidemiology a single-stranded, positive-sense RNA virus, togavirus family, one serum type. Humans as the only host Spread either by oral droplet or transplacentally to fetus causing congenital infection Contagious period: 5 days before until 7 days after onset of the rash. Peak incidence in children 1~5 yr of age

  38. Clinical manifestations Incubation stage (14 to 21 d) Prodromal stage (1-2d) Mild catarrhal symptoms with shorter period Low-grade fever (1~3d) with mild systemic symptoms. About 2/3 are subclinical. Eruption stage

  39. Eruption stage The most characteristic sign： Enlarged post-occipital, retroauricular and posterior cervical lymph nodes accompanied by amaculopapular, discrete rash. The rash begins after 1-2d of fever, on the face and spreads to the body in 1d and lasts for 3 days.

  40. Congenital rubella (syndrome) Affects virtually all organ systems Thecommon manifestation is:intrauterine growth retardation Never system: microcephaly, deafness Eye: microphthalmia, cataracts, glaucoma, chorioretinitis Blood system: anemia, thrombocytopenia, leukopenia, Skin and others: blueberry muffinrash,hepatosplenomegaly, jaundice,PDA B cell and T cell deficiency infant may be asymptomatic at birth.

  41. Diagnosis Apparent diagnosis based on clinical symptoms and signs Laboratory findings non-specific and generally do not aid in diagnosis Confirmed by serology or virus culture Congenital rubella: serum IgM or virus culture Prenatal diagnosis: cord blood IgM or virus culture from amniotic fluid

  42. Treatment and prognosis There is no specific antiviral therapy Entirely supportive, and antipyretics The prognosis is excellent, but congenital rubella syndrome may have sequalae such as intrauterine growth retardation, cataracts, deafness, and PDA.

  43. Prevention Live rubella vaccine recommended as MMR for children( initial at 12-15m and second 4-6y) It is important for girls to have immunity before they reach childbearing age.

  44. Roseola infantum

  45. Etiology Human herpesvirus (HHV) type 6 (HHV-6), HHV-7. Large, enveloped double-stranded DNA viruses, members of the herpesvirus family. Infect mature mononuclear cells and cause a relatively prolonged (3 to 5 days) viremia during primary infection. Be detected in the saliva of healthy adults, which suggests,the development of lifelong latent infection and intermittent shedding of virus.

  46. Epidemiology Transplacental antibody protects most infants until 6 months of age. Primary HHV-6 infection occurs early in life with peak acquisition from 6-15 months of age. By 12 months of age, approximately 60% to 90% of children have antibodies to HHV-6, and essentially all children are seropositive by 2 to 3 years of age. The virus is likely acquired from asymptomatic adults who periodically shed these viruses.. HHV-6 and HHV-7 can cause encephalitis in immunocompromised persons. HHV-6 can be transmitted in utero.

  47. Cinical manifestations Incubation period: 5-10d Prodromal period: Usually asymptomatic Mild URT signs Mild cervical lymphadenopathy

  48. Cinical manifestations Clinical illness heralded by high fever 37.9~40.0 with an average of 39℃ Persists for 3-5 days and then resolves rather abruptly. Occasionally fever diminish over 24-36h gradually. May be irritable and anorexia but most behave normally Seizures in 5~10%. Roseola is associated with approximately one third of febrile seizures. Infrequent : rhinorrhea, sore throat, abdominal pain, vomiting and diarrhea.

  49. Cinical manifestations Eruption and fever A rash appears within 12~24 hours of fever resolution Eruption during defervescence or within a few hours of fever resolution

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