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Hot Spots (Or Red Rashes With Fever). Yasmin Tyler-Hill, M.D. Clinical Assistant Professor Department of Pediatrics Morehouse School of Medicine. Objectives. Recognize rashes that are included in the differential diagnosis of Rheumatologic diseases

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hot spots or red rashes with fever

Hot Spots(Or Red Rashes With Fever)

Yasmin Tyler-Hill, M.D.

Clinical Assistant Professor

Department of Pediatrics

Morehouse School of Medicine

objectives
Objectives
  • Recognize rashes that are included in the differential diagnosis of Rheumatologic diseases
  • Differentiate common and uncommon but serious diseases that present with fever and rash
so what hot spots do we visit
…So, What Hot Spots Do We Visit
  • Kawasaki’s
  • Steven’s Johnson
  • Rocky Mounted Spotted Fever
  • Measles
  • Group A Strep/Toxic Shock Syndrome
  • Henoch Schoenlein Purpura
  • Roseola
case 2
Case #2
  • 20 month old female presents to your office with a 5 day history of fever and irritability. She was seen in the local ER 3 days ago and was given Amoxicillin for an ear infection. Mom stopped the amoxicillin this morning secondary to a rash.
  • What do you want to know?
case 1
Case #1
  • HPI: Temperature up to 103. Mother is using Tylenol and Motrin with relief, but the fever returns. Child also has been more irritable than usual, difficult to console. He has been drinking less with decrease urine output
case 16
ROS:

Fever (104)

Irritability

Decreased PO intake

Decreased UOP

Rash

Vomited x 1

NO diarrhea

NO SOB

NO pain

No sick contacts

FH

Sickle cell trait

Asthma

SH

Lives with mom and dad

Only child

Attends daycare

Immunization

UTD

Case #1
case 1 physical exam
Case #1 Physical Exam
  • Vital Signs:
    • T: 39 HR: 138 RR: 30 BP: 90/50
  • HEENT: NCAT, slightly dry / cracked MM, injected conjunctiva, normal turbinates, TM’s erythematous bilaterally, OP with erythematous tongue and white tonsilar exudate
  • Neck- bilateral cervical lymphadenopathy (1.5 cm on right and 0.5 cm on the left)
case 1 physical exam cont
Case #1 Physical Exam (Cont.)
  • Lungs: CTA bilaterally, no wheezes, no rales
  • CV: Tachycardic , normal rhythm, pulse 2+
  • Abdomen: soft, NTND, good bowel sounds
  • Skin: red, blanching, slightly raised, polymorphous rash over her extremities
  • Neurological: irritable, difficult to console
  • Genitalia: normal female, desquamation of the area
  • Extremities/ MS- FROM, puffy hands, good tone
case 1 laboratory evaluation
Case #1 Laboratory Evaluation
  • WBC 15,000
    • 20 bands, 52 neutrophils, 22 lymph, 6 monocytes
  • H/H 9.7/ 30. Platelets 700,000
  • UA – sp.grav 1.030, ketones 2+
  • Electrolytes- normal
  • Blood Culture, Urine culture, ? CSF culture
kawasaki disease
Kawasaki Disease
  • Epidemiology
    • Affects all races, seen throughout the world (Asian descent affected more often)
  • 80% in children less than 5, rarely teenager and adults
  • Boys: Girls = 1.5:1
  • In US about 3000 children hospitalized annually
  • 0.4%-2.0% mortality rate
  • 20-25% with cardiac complications
case 1 diagnosis and treatment
Case #1 Diagnosis and Treatment
  • Diagnosed with Kawasaki disease
    • Kawasaki disease is a generalized, acute vasculitis of unknown cause
  • Received IVIG
  • Started on Aspirin
  • Cardiac Echo
  • Improved within 12 hours
kawasaki disease clinical diagnosis
Kawasaki Disease: Clinical Diagnosis
  • FEVER plus 4 of the 5
    • Bilateral, non exudative conjunctival injection
    • injected or fissured lips, injected pharynx, or strawberry tongue
    • erythema of palms or soles, edema of hands or feet, or periungual desquamation
    • Polymorphous exanthem
    • Acute, nonsuppurative cervical lymphadenopathy (at least one node ≥1.5 cm in diameter)
kawasaki disease evaluation
Kawasaki Disease: Evaluation
  • Three phases
  • Although no specific “test”, abnormal labs seen are leukocytosis, elevated erythrocyte sedimentation rate, thrombocytosis, and sterile pyuria.
  • Unknown cause
  • Morbidity and Mortality related to coronary artery thrombosis in 20-25% of children
kawasaki disease management
Kawasaki Disease: Management
  • IVIG
  • High dose Aspirin
  • Cardiac Echo
  • Follow -up
case 218
Case #2

This 8 year old girl developed upper respiratory symptoms with fever, cough, tachypnea, and malaise several days before a purulent conjunctivitis, erosive oral mucositis, and blistering skin rash. The cutaneous lesions were relatively limited, and the oral lesions and conjunctivitis began to improve 3 to 4 days later. Rapid diagnostic tests for Mycoplasma pneumoniae were positive. Interestingly, her mother had a history of pneumonia treated with oral antibiotics several weeks earlier, and her sister developed a cough and mild but similar rash several days after the patient was hospitalized.

slide19

Purulent conjunctivitis with edematous lids and conjunctival hemorrhage, cheek and chin vesicles, intranasal and lip erosions

slide20

Diffuse red macules many with central necrotic bulla and erosions and associated conjunctivitis and mucositis

slide22

Diffuse red papules and plaques some with central necrotic bullae, erosions of the conjunctivae and oral mucosa

stevens johnson syndrome
Stevens-Johnson Syndrome
  • Cell mediated hypersensitivity response
  • Clinical Presentation
      • Multiorgan/systmem involment –eye, kidney, liver
      • Skin and mucosal
  • Precipitating Factors
      • Drugs –Abx & anticonvulsants
      • Infective agents –Mycoplasma &herpes simplex
  • Management
slide24

A diffuse scarlatiniform eruption developed on this 4-year-old boy who demonstrates his strawberry red tongue and red and fine scaly papular rash. A throat culture was positive for Group A beta-hemoplytic Streptococcus

slide25

A healthy 6-year-old boy developed a diffuse papular eruption in association with headache, sore throad, and fever. His throat culture was positive for Group A beta-hemolytic streptococcus, and he improved within several days on oral amoxacillin.

slide26

Peeling with minimal underlying erythema

This 4-year-old boy with a history of atopic dermatitis was treated for right sided mastitis with topical mupirocin ointment. He subsequently developed a disseminated red sand paperlike eruption. A throat culture was positive for Group A beta-hemolytic streptococcus, and he was treated with oral erythromycin because of a history of penecillin allergy. He subsequently developed widespread desquamation with the most prominent lesions on the hands and feet.

slide27

This 8-year-old girl developed a red papular eruption on her lower extremities and a disseminated sandpaper-like rash 3 days after the onset of a sore throat with a positive Group A beta hemolytic streptococcus culture. She also had a strawberry tongue with a white membrane and prominent red papillae poking through the coating.

group a streptococcal infections
Group A Streptococcal Infections
  • Clinical Manifestations
    • Respiratory
    • Skin
    • Other
    • Sequelae
  • Management
    • Diagnosis
    • Treatment
proposed case definition for the streptococcal toxic shock syndrome
Proposed Case Definition for the Streptococcal Toxic Shock Syndrome
      • Isolation of group A streptococci
      • Hypotension: systolic blood pressure 90 mm Hg in adults or <5th percentile for age in children
  • AND
      • Two or more of the following signs
        • Renal impairment
        • Coagulopathy:
        • Liver involvement
        • Adult respiratory distress syndrome
        • A generalized erythematous macular rash that may desquamate
        • Soft-tissue necrosis, including necrotizing fascitis or myositis, or gangrene
case 3
Case # 3

This healthy 10-year-old girl developed purpuric papules consistent with a leukocytoclastic vasculitis on her distal extremities several weeks after a viral upper respiratory infection. She had migratory swelling of the hands and feet and intermittent crampy abdominal pain. Her urinalysis and blood pressure were normal. A skin biopsy from a lesion on the top of the foot showed a leukocytoclastic vasculitis, and direct immunofluorescence demonstrated deposition of IgA around dermal blood vessels.

case 4
Case # 4

A 6-year-old boy comes to your office because of migratory painand swelling of his joints. Three days ago he experienced painand swelling of his right hand and knee. The following day,the pain and swelling had spread to his right ankle. He complainsnow only of right ankle and lower back pain. The joints werewarm, but no erythema was noted. The child has been healthy, withno history of fever, runny nose, cough, vomiting, sore throat,or diarrhea. He was bitten by a tick 4 months ago. There isno family history of arthritis.

Physical examination reveals a friendly boy in no obvious distress. Hisvital signs, including blood pressure, are normal, as are theresults of his entire examination, except for marked swelling,erythema, and tenderness of the right ankle, which has limitedrange of motion. There is tenderness on palpation of the sacroiliacjoints, but no obvious swelling or limitation of motion is appreciated.There are no rashes.

Laboratory testing reveals: white blood cell count, 13.2 x 109/L (13.2x 103/mcL); hemoglobin, 8.93 mmol/L (14.4 g/dL); platelet count,306 x 109/L (306 x 103/mcL); erythrocyte sedimentation rate, 11mm/hr; normal findings on urinalysis; negative throat culture, anti-streptolysinO titer, anti-DNAse B titer, Lyme titer, mononucleosis test, andEpstein-Barr titers. Radiographs of the right ankle and lumbosacral spineshow no bony abnormalities.

case 4 con t
Case # 4 (con’t.)

Upon his return to the office, the boy was noted to have a purple, papularrash on his buttocks and lower extremities and was experiencingsevere abdominal pain and swelling of his left elbow, a constellationof findings characteristic of Henoch-Schöenlein purpura(HSP).

henoch schoenlein purpura
Henoch-Schoenlein Purpura
  • Leucocytoclastic vasculitis
  • Clinical Presentation
    • Rash, angioedema
    • Arthritis or arthralgias
    • GI
      • 50% of affected children
      • Colicky abd pain, GI bleeding, rarely intussusception
    • Kidney disease
      • 25-50%
      • Hematuria –endstage renal disease
  • Management
case 5
Case # 5

A healthy 14 month old developed a red papular morbilliform eruption after 3 days of high fever without a source. The rash begin at his head and spread distally. The rash cleared in the same manner. The asymptomatic rash appeared as he deffervesced and lasted less than 24 hours.

case 6
Case # 6

A 9-month-old girl is brought to the clinic because of worseningfever and rash. Three days ago, she developed a fever of 38.8°C(101.8°F) and pinpoint flesh-colored "bumps" on the abdomen.The rash soon turned red and quickly spread to the entire body,but it was not pruritic. The following day she developed clearrhinorrhea and a cough severe enough to cause posttussive emesis. Thefever persisted for the next 2 days despite administration of ibuprofen.The increasing irritability and fever of 40.0°C (104°F) promptedher mother to bring her to the clinic. The child’s appetiteis poor, but she does drink, and her urine output has not diminished. Thereis no diarrhea. Her mother denies administering any medication otherthan ibuprofen. The child has been healthy previously, and her motheris unaware of any known illness contacts. She has received herprimary immunization series for diphtheria, tetanus, pertussis,polio, Haemophilus influenzae type b, and hepatitis B. Of note,she and her family traveled cross-country by automobile 2 weeksago.

case mealses
Case mealses

Physical examination reveals an irritable but consolable infantwho has a red rash consisting of raised spots and flat, confluentpatches (Fig. 1 ). She has a temperature of 38.3°C (101.8°F),respiratory rate of 42 breaths/min, and pulse of 152 beats/min.Discrete, intensely red, raised lesions extend over the face(Fig. 2 ), trunk, and extremities. Flat, red spots appear onthe palmar surfaces (Fig. 3 ). No blisters or small, purplehemorrhages of the skin are present. Examination of the headshows conjunctival injection without discharge; clear rhinorrhea; twograyish-white, pinpoint, elevated spots on the right buccalmucosa; and palpable, mobile lymph nodes in the posterior cervicalregions. Auscultation of the chest demonstrates bilateral clearbreath sounds and normal S1 and S2 heart sounds without a murmur.Findings on abdominal, genitourinary, and neurologic examinationsare unremarkable.

mealses
Mealses
  • Epidemiology
    • Occurs in unimmunized preschoolers and teens missing 2nd immunizaation
  • Clinical Presentation
    • Incubation stage (10-12 days)
    • Prodromal stage (3-5 days)
      • Koplick spots, conjunctivits, coryza, fever, cough
    • Exanthem Stage
      • Red macular papular rash, high fever
  • Complications
      • Pneumonia, croup, OM, acute and subacute encephalitis,
  • Transmission
      • Highly contagious
slide49

This 9 year old boy developed a red partially blanching papular eruption on his hands and feet including his palms and soles that progressed to the trunk over 3 days. He had a severe headache, high fever, arthralgias and myalgias. His mother, who remembered removing a wood tick from her son's scalp 10 days earlier also developed a rash, fever, and headache.

slide50

An ill appearing toddler with high fever and a diffuse red rash and edema suddenly developed diffuse petechiae and ecchymoses. Laboratory studies showed a prolonged bleeding time, thrombocytopenia, anemia, and neutropenia. After a prolonged course in the pediatric intensive care unit, he recovered uneventfully with the exception of necrosis of the tips of several toes.

slide51

Large (8 m body) 8-legged arachnid; black with brown leather pattern on body and legs

In the United States the most common vectors of Rickettsia rickettsii include Dermacentor variabilis (American dog tick), Dermacentor andersoni (wood tick), and Amblyomma americanum

rocky mounted spotted fever
Rocky Mounted Spotted Fever
  • Rickettsia rickettsii gram neg intracellular coccobacillus
  • Clinical Presentation
    • HA, myalgias followed by rash on day3-5
    • Systemic-conjunctivitis,hypotension,renal,CNS,coagulopathy
  • Diagnosis
    • Indirect Fluorescent Antibody—6-10 days into illnes
    • PCR specific not sensitive
    • Bx—need expert for correct interpretation
  • Treatment
    • Doxycycline for all ages
    • Chloramphenicol
    • Duration 7-10 days
references

Theoklis Zaoutis and Joel D. KleinEnterovirus InfectionsPediatr. Rev., Jun 1998; 19: 183 - 191.

References
  • L. Akinbami and Tina L. ChengRocky Mountain SpottedFeverPediatr. Rev., May 1998; 19: 171 - 172.
  • Theoklis Zaoutis and Joel D. KleinEnterovirus InfectionsPediatr. Rev., Jun 1998; 19: 183 - 191.
  • Anjali Jain and Robert S. DaumStaphylococcal Infections in Children: Part 3Pediatr. Rev., Aug 1999; 20: 261 - 265.
  • Muhammad Waseem and Heidi PinkertVisual Diagnosis: A Febrile Child Who Has "Red Eyes" and a RashPediatr. Rev., Jul 2003; 24: 245 - 248.
  • http://dermatlas.med.jhmi.edu/derm/