FEVER AND RASH Flashcards by Maria Hazel Quiban

_________: 4 serotypes
•Carried by Aedes aegypti
•

•Dengue virus

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____________ is usually associated with secondary dengue infections

Dengue hemorrhagic fever

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Etilogy: RNA virus (Paramyxoviridae Family)
Mode of Transmission: by droplet spray during the prodromal period
Period of communicability: 4 days before & 4 days after the onset of the rash

RUBEOLA (MEASLES)

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Pathognomonic Sign:
•Koplik spots
Øgrayish white dots with red border opposite the lower molars
Øappear before the prodrome

RUBEOLA/ MEASLES

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WHAT ARE THE 3C’s prodrome in rubeola/ measles?

•prodrome: high-grade fever + 3 C’s (conjunctivitis, cough, coryza) for 3-5 days

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@ height of fever: maculopapular rash appears on the hairline or face and spreads cephalocaudally
Rash fades downward à branny desquamation and disappears within 7-10 days

RUBEOLA/ MEASLES

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•Vitamin A:
–single dose
–100,000 IU orally for 6 mo-1 yr
–200,000 IU for > 1 yr old
–Especially indicated for hospitalized patients & with complications (ophthalmologic evidence of vitamin A deficiency & malnourished patients)

Rubeola/ measles

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Measles: Complications

Otitis media
Pneumonia
Encephalitis (Subacute sclerosing panencephalitis)

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Caused by: altered measles virus harbored intracellularly in CNS
Occurs 7-10 years post measles infection

Subacute sclerosing panencephalitis

(SSPE)

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What happens in the stage 1 of SSPE?

Stage 1
Subtle changes in behavior & deterioration of schoolwork, decreased attention span, temper outbursts

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What happens in the stage 2 of SSPE?

Stage 2
Massive, repetitive myoclonic jerks esp. of the axial muscles

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What happense in the stage 3 of SSPE?

Stage 3
Choreo-athetosis, rigidity, dystonia, decreased sensorium, dementia, stupor, coma

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What happens in stage 4 of SSPE?

Stage 4
loss of central control for breathing, heart rate, blood pressure
è death

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Due to RNA virus of Togaviridae family
Spread by oral droplet or transplacentally to the fetus
Period of highest communicability: 5 days before & 6 days after the onset of the rash

German Measles/ Rubella

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•Forchheimer spots
Ødiscrete rose spots on the soft palate
Øjust before the onset of rash
20% of patients

Rubella: Clinical Manifestations

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The Rash

can be the first symptom to appear
maculopapular rash begins on the face and spreads quickly cephalocaudally
Duration: 3 days
w/o desquamation

•low grade fever for 1-3 days
•retroauricular, posterior cervical & suboccipital lymphadenopathy (begins 24 hrs before the rash and remains for 1 week)
•Polyarthritis esp.in older girls

RUBELLA

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RNA virus

(Togaviridae Family→ replicates in the respiratory epithelium
•spreads to regional lymph nodes→spreads to regional lymph nodes

RUBELLA

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Risk for congenital defects & disease is greatest with primary maternal infection during the 1st trimester

Congenital Rubella

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Intrauterine growth retardation
Congenital cataracts
Microcephaly
Structural heart defects like PDA
“blueberry muffin” skin lesions
Sensorineural Hearing Loss
Motor and mental retardation

Congenital Rubella

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Human herpesvirus type 6
Aka Exanthem Subitum, Sixth disease

ROSEOLA

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•High grade fever for 3-5 days
•Rash appears coincident with resolution of fever
•Rash: small, evanescent morbilliform, blanching, pink (rose-colored) rash
•Appears on trunk è to face & extremities
lasts for 1-3 days

ROSEOLA

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•Nagayama spots: ulcers at uvulopalatoglossal junction
•Mild injection of pharynx, palpebral conjunctivae, or tympanic membranes
•Enlarged suboccipital nodes
•
Pathophysiology: Unknown

ROSEOLA

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_____________is a neurotropic human herpes virus
Chickenpox: primary infection

•Period of communicability: 1-2 days before the rash until all lesions have crusted

Varicella zoster virus

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•_________ activation of latent sensory ganglion neurons

Herpes Zoster (shingles):

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* The Rash * Trunk àother parts of the body * Macule/papuleà vesicleà crust * In various stages are of evolution

Varicella

Pathogenesis: ## Footnote Human herpes virus * Inoculates in mucosa of the upper respiratory tract and tonsilar lymphoid tissue * spreads to reticuloendothelial system * Viremia è Cutaneous lesions

Varicella

* The Rash * same as varicella with severe pain & tenderness along the posterior nerve roots

Herpes Zoster

* The Rash * same as varicella with severe pain & tenderness along the posterior nerve roots

herpes zoster

Human herpes virus * Transported via sensory axons to the dorsal root ganglia (during 10 infection) * Latent infection in neurons and satellite cells * reactivatiionè rash within dermatomal distribution

Herpes Zoster

What are the secondary complications of Varicella?

* secondary bacterial infection * encephalitis or meningitis * Pneumonia * glomerular nephritis

* Fetuses infected at 6-12 wks of gestation have maximal interruption of limb development à short & malformed limbs covered with cicatrix – skin lesion with zigzag scarring * Fetuses infected at 16-20 wks of gestation - eye & brain involvement

Congenital Varicella

* Most common cause: Coxsackievirus A16 * Enterovirus 71: more severe

HAND, FOOT & MOUTH DISEASE (HFMD

The Rash ØTender maculopapular, Ulcerative intraoral lesions on tongue & buccal mucosa Øvescicular, pustular lesions on hands & feet

HFMD

What are the complications of HFMD

•Complication: myocarditis, pericarditis, shock

* **parvovirus B19** * Common in 5-15 years old * Transmission: large droplet spread & blood transfusion

ERYTHEMA INFECTIOSUM

* Fifth disease * Incubation period: 16-17 days * Infectious stage: low grade fever, malaise, rhinorrhea * post-infectious stage: Rash, joint pains

ERYTHEMA IN**F**ECTIOSUM

Parvoviris B19 * Viremia * Fever, Malasie, * rhinorrhea Attacks erythroid cell line •Fall in hemoglobin •transient arrest of erythropoiesis

ERYTHEMA INFECTIOSUM: Infectious stage

ERYTHEMA INFECTIOSUM Fall in Hemoglobin and arrest of eryhtropoiesis is DANGEROUS for:

1. Immunocompromisedà chronic infection (chronic anemia) 2. chronic hemolytic diseaseà transcient aplastic crisis 3. pregnant women (fetus) à fetal anemiaàfetal demise

Tx for Erythema Infectiosum 1. Immunocompromisedà chronic anemia: \_\_\_\_\_\_\_\_\_\_ 2. chronic hemolytic diseaseà transcient aplastic crisis: \_\_\_\_\_\_\_\_\_\_\_\_ 3. pregnant women (fetus) à fetal anemia: \_\_\_\_\_\_

1. IVIG 2. PRBC transfusion 3. in-utero rbc transfusion

ERYTHEMA INFECTIOSUM: Post infectious stage

* Th-1–mediated cellular immune response→ * production of specific immunoglobulin M (IgM) antibodies→ * formation of immune complexes→ * deposition of the immune complexes in the skin, joints Rash, Arthralgia

RASH: 3 phases I: **“slapped-cheek”** è macular erythema on trunk & proximal extremities è Central clearing II: **lacy, reticulated appearance** •Fades without desquamation III: **wax & wane in 1-3 weeks**

Erythema Infectiosum

* **Neisseria meningitidis** * **Groups A, B, C, W135, Y** – more common * 6-12 months age group * Secretions from colonized upper RT of patients & asymptomatic carriers •Mode of transmission: person to person through infected droplets •Period of communicability: until 24 hours after start of antibiotics •Asymptomatic colonization to fulminant sepsis **•**

**MENINGOCOCCEMIA** •Mode of transmission: person to person through infected droplets •Period of communicability: until 24 hours after start of antibiotics •Asymptomatic colonization to fulminant sepsis •

•Clinical Manifestations •**Abrupt** onset of fever, chills, headache, vomiting •**Rapid worsening of symptoms within hours** •Diffuse adrenal hemorrhage, DIC, coma and death à **Waterhouse-Friderichsen syndrome** • •

MENINGOCOCCEMIA

Menigococcemia

N. meningitis

Rocky Mountain Spotted Fever (RMSF) causative agent is\_\_\_\_\_\_\_\_ –intracellular bacteria •Ticks: natural host, reservoir, vectors

Rickettsia rickettsii

Rocky Mountain Spotted Fever Clinical features •What is the Triad: \_\_\_\_\_\_\_\_\_\_\_\_ •**Calf muscle** pain and tenderness •GIT: nausea, vomiting, diarrhea, abdominal pain

Fever, headache, rash

RMSF

The rash –Discrete, pale, rose-red blanching maculopapules on ankles, wrist, lower limbs, spread to trunk – petechiael or hemorrhagic – **echymoses, necrotic (in severe cases)**

RMSF

Rocky Mountain Spotted Fever Treatment \_\_\_\_\_\_\_\_\_\_\_\_\_ (drug of choice)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ RITTER DISEASE •Common in **less than 5 yrs old** •Most common cause: **phage group 2 staphylococci**, particularly **strains 71 and 55**

Staphylococcal Scalded Skin Syndrome (SSSS)

: Clinical Manifestations •Rash may be preceded by **malaise, fever, irritability, and exquisite tenderness of the skin** •**Scarlatiniform erythema** develops diffusely and is accentuated in flexural and periorificial areas •The conjunctivas are inflamed and occasionally become purulent

SSSS

The Rash •**Brightly erythematous ski**n  wrinkled appearance  blisters and erosions •Circumoral erythema, radial crusting and fissuring around the eyes, mouth, and nose

SSSS

**Nikolsky sign** = areas of epidermis may separate in response to gentle shear force •Large sheets of epidermis may peel away  moist, glistening, denuded areas  secondary cutaneous infection •Desquamative phase begins after 2–5 days of cutaneous erythema •Healing occurs without scarring in 10–14 days

SSSS

SSSS: Treatment

* Antibiotics: Oxacillin * Clindamycin may be added to inhibit bacterial protein (toxin) synthesis * The skin should be gently moistened and cleansed * Application of an emollient provides lubrication and decreases discomfort

* Menstruating women 15-25 yo * Use of tampons * Non-menstrual TSS: nasal packing, wound infection, sinusitis, tracheitis, pneumonia, emphysema, abscess, osteomyelitis, burns

Staphylococcal Toxic Shock Syndrome

Staphylococcal Toxic Shock Syndrome: Diagnostic Criteria

Major Criteria (all required) Acute Fever \>38.8C Hypotension Rash (erythroderma w/ convalescent desquamation)

Staphylococcal Toxic Shock Syndrome: Diagnostic Criteria

Minor Criteria (3 or more) Mucous membrane inflammation Vomiting, diarrhea Renal abnormalities Liver abnormalities Muscle abnormalities CNS abnormalities Thrombocytopenia (\<100,000/mm3)

Staphylococcal Toxic Shock Syndrome: Diagnostic Criteria Exclusionary Criteria

Absence of another explanation Negative blood culture (except for Staph.aureus)

SSSS

pathogenesis Scarlet and SSSS

\_\_\_\_\_\_\_\_\_\_\_\_: Clinical Manifestations •The Rash –**begins around the neck and spreads over the trunk and extremities** –papular, erythematous rash that blanches on pressure **and feels rough (sandpapery)** –lasts 3–4 days fades desquamation

Scarlet Fever

\_\_\_\_\_\_\_\_\_\_: Clinical Manifestations **•Fever •Pharyngitis *•Strawberry tongue***

Scarlet Fever

Scarlet Fever: Strawberry tongue

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ •Fever, rash •Shock •Multiorgan system failure

Streptococcal Toxic Shock Syndrome

Streptococcal Toxic Shock Syndrome: Cinical Criteria •Hypotension + 2 or more of the ff:

Renal impairment Coagulopathy Hepatic impairment Acute Respiratory Distress Syndrome Generalized erythematous macular rash Soft tissue necrosis

\_\_\_\_\_\_\_\_\_\_\_\_\_ Definition: \_\_\_\_\_\_\_\_\_\_\_ is an autoimmune disease affecting the **heart and extra- cardiac sites (joints, brain, skin and others)** •Develops **2-3 weeks after an acute episode of pharyngitis** Group A Strep (GAS)

Rheumatic Fever (RF)

Jone's Criteria f What are the major classification?

* Carditis (friction rub, murmur, cardiomegaly, CHF) * Arthritis (migratory polyarthritis, swollen, red, tender) * Chorea * Subcutaneous nodules * Erythema marginatum

Jone's Criteria What are the minor classification?

* Fever * Arthralgia * Acute phase reactants (ESR, C-reactive protein, leukocytosis) * Prolonged P-R interval on ECG

\_\_\_\_\_\_\_\_\_\_\_ •2 Major Criteria •OR •1 Major + 2 Minor Criteria + supporting evidence of antecedent Group A streptococcal infection

Jones Criteria

\_\_\_\_\_\_\_\_\_\_ characterized by the development of **Aschoff’s Bodies** within the **myocardium** Gross features: •**Aschoff bodies are multiple tiny nodules (1-2 mm in diameter)**

Carditis:

Microscopic features: 1. Fibrinoid necrosis ( destroyed fragmented collagen) 2. Surrounded by lymphocytes and histiocytes & 3. Aschoff cells (large mononuclear or multinuclear macrophages)

Aschoff’s body

Rheumatic Mitral Valve

Erythema Marginatum

secondary prevention RF

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ •Acute febrile vasculitis •Affects medium-sized artery w/ striking predilection for the coronary arteries •20% of untreated cases develop coronary artery aneurysm •Unknown cause

KAWASAKI DISEASE

KAWASAKI Fever x 5 days + 4 of the ff:

CONJUNCTIVA –bilateral, non-exudative RASH - ADENOPATHY – unilateral, cervical, \>1.5cm STRAWBERRY TONGUE, erythema of oropharyngeal mucosa, dry cracked lips HANDS & FEET EDEMA CRASH & BURN

\_\_\_\_\_\_\_\_\_\_\_\_\_ •The Rash –Maculopapular –Erythema multiforme or –Scarlatiniform

KAWASAKI DISEASE

\_\_\_\_\_\_\_\_\_\_ •Conjunctivitis •Strawberry tongue •Perineal desquamation

KAWASAKI DISEASE

Periungual desquamation

Kawasaki Disease

KAWASAKI DISEASE Clinical Phases Phase Symptoms Timing ACUTE Febrile

•CRASH & BURN •Perineal desquamation •Myocarditis 1st-2nd week of illness

What is the SUBACUTE phase of Kawasaki?

* Fever has resolved * Irritability, conjunctivitis,anorexia * Periungual desquamation of fingers and toes * Arthritis * CORONARY ARTERY ANEURYSM

What is the CONVALESCEN phase of Kawasaki?

CONVALESCENT •Clinical signs and symptoms have abated •ESR and CRP still elevated Until 6-8 weeks after onset

* Main symptom: Arthritis * Systemic-onset JRA: fever and rash * Other types: oligoarthritis and polyarthritis

Juvenile Rheumatoid Arthritis (JRA)

Systemic-onset _____________ Clinical Features •Fever •Rash •Arthritis •Visceral involvement •Hepatosplenomegaly, lymphadenopathy, serositis **•(+)Koebner phenomenon**

JRA

Systemic-onset JRA Clinical Features •The rash –**Transient/Evanescent (\<1hr)** –Faint, erythematous, salmon-colored, macular, linear or circular on trunk and proximal extremities **–Non-pruritic**

JRA

Systemic-onset JRA Clinical Features

FEVER AND RASH Flashcards

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