Fever and Rash

Fever and Rash
Presentation by:Marcellina Mian
Professor of Pediatrics

* Macule: discolored spot (often, but not necessarily red; often, but not necessarily round); blanches
* Papule: raised spot
* Maculopapular: a papule rising from a macule, often red
* Petechia: pinpoint purple/red bruise; does NOT blanch, often in clusters
* Ecchymosis: red/purple bruise, variable size & shape

Definitions
Case #1
Maculopapular rash
Measles
* “Stepwise” high fever
* Cough, coryza, and conjunctivitis
* Rash (exanthem) starts on head & spreads to rest of body
* Koplick spots (enanthem) prior to or at very beginning of rash
* Complications: OM, diarrhea, encephalitis, pneumonia

Koplick Spots
Measles (Rubeola)
* Highly contagious
* Most deadly of all childhood rash/fever illnesses
* Spread by droplets or direct contact with nasal or throat secretions of infected persons
* Incubation period: 8 -12 days
* Prevention: immunization (MMR) just past one year & before kindergarden

Case #2

13-year-old male with:
* fever x two days
* generalized rash
On PE:

* Well & comfortable
* Maculopapular rash
* Postauricular lymphadenopathy

Rubella (German Measles)
* Low grade fever
* Rash:
o starts on face & spreads down body, clearing in same pattern
o Light red spots, fainter than measles
o Lasts 1 - 3 days
* Mild illness, may be missed
* Adults & adolescents may have arthritis or arthralgia
* Complications: encephalitis, neuritis & in pregnancy  Congenital Rubella Syndrome in baby

Congenital Rubella

* Rash
* Cataracts
* CHD (PDA)
* Blindness
* Neurosensory deafness
* Microcephaly & mental retardation

Rubella

* Droplet transmission
* Incubation period: 2 - 3 weeks
* Prevention: Vaccination (MMR)

Case #3

* 15-month-old presents with several days of fever, & rash that looks like this:

Fifth Disease, Erythema Infectiosum
* Parvovirus B19
* Fever, malaise & headache may precede rash by up to 10 days
* “Slapped cheeks” and “lacy, reticular” rash over body that may itch
* No longer infectious once rash develops
* Virus may also cause polyarthropathy syndrome, aplastic crisis, or hydrops fetalis

Hydrops Fetalis

Case #4

* 8-month-old female with fever to 40C for past 5 days
* Baby does not look unwell
* PE reveals no source of fever
* U/A negative
* WBC mildly elevated; mostly lymphocytes
* D/C on acetaminophen
* Next day mother calls to say baby has a rash

Roseola (Sixth disease, Exanthem subitum)
* Peak incidence 6-24 months
* 20% of HHV-6 infections
* Also HHV-7
* Self-limited disease:
o 3-7 days of fever
o Rash follows defervescence
* Febrile seizures in 10-15%
* Occasionally, bulging fontanelle & encephalopathy

Case #5

* 3-year-old boy with fever & irritability x 6 days.
* PE:
o maculopapular rash
o red eyes
o strawberry tongue
o cervical lymphadenopathy

Scarlet Fever

* Group A Strep
* Generalized rash:
o Sandpapery
o Circumoral pallor
o Pastia’s lines

Pastia’s lines
Circumoral pallor
Kawasaki Syndrome Mucocutaneous Lymph Node Syndrome 3 phases:

* Acute: 1-2 wks, fever, etc
* Subacute: 2-4 wks
o After acute signs
* Convalescent: 6-8 wks
o about 4th wk; when clinical signs disappear
o Until ESR returns to normal

Kawasaki Syndrome Mucocutaneous Lymph Node Syndrome
Acute Phase:
Subacute phase
Associated findings:
Kawasaki Syndrome: Coronary aneurysm
Kawasaki Syndrome: Treatment

Case #6
Lyme disease in
Erythema chronicum migrans
* Borrelia burgdorferi transmitted by:
* Ixodes tick
o Ehrlichia, babesia
Lyme Disease: early localized
* Erythema migrans:
Lyme Disease: early disseminated
Lyme Disease: late disseminated

Case #7
Epstein Barr Virus
Infectious Mononucleosis

Case #8
Scarlet Fever
Case #9
Neisseria meningococcemia
Case #10
HSV Stomatitis
Whitlow
Case #11
Hand-Foot-and-Mouth Disease
* Coxsackie A16 & Enterovirus 71
* Oral lesions only: herpangina
* Vesicles on an erythematous base, at posterior pharynx/soft palate
* Commonly presents in spring & summer
* Supportive care

Case #12
* 2-year-old child presents with fever for four days & rash for two days.
* His father, who is visiting from Mexico to harvest strawberries, brought him to a walk-in clinic.

Varicella
* Herpes virus, vaccine preventable
* Incubation period: 14-16 days Prodrome: fever, constitutional symptoms, then rash starting on trunk & spreading to limbs (centrifugal)
* “Dewdrop on a rose petal”
* Vesicles in various states of evolution
* Contagious until all lesions crust over

Fever and Rash.ppt

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Infectious Disorders

Infectious Disorders
Presentation from: Chipola College

Stages of infectious disease
* Incubation period
o Time between the invasion of an organism & the onset of S/S
o 7-10 days (maybe longer depending upon pathogen)
* Prodromal period
o Time between the beginning of nonspecific symptoms & specific symptoms
o Hours to a few days
* Illness
o Specific symptoms are evident
* Convalescent period
o Time between when the S/S begin to fade and a return to full wellness

Chain of infection
* Reservoir
o Place in which organisms grow & reproduce
* Portal of exit
o Method by which organisms leave an infected person’s body to be spread to another individual
o Table 43-1 (blood, respiratory secretions, feces, & exudate from lesions)
* Means of transmission
o Direct contact, indirect contact, fomites (inanimate objects, ex. food, bedding, towels, combs, drinking glasses, etc), insects, or vermin
* Portal of entry
o Means by which a pathogen can enter an individual’s body
o Inhalation, ingestions, breaks in the skin (ex. bites, abrasions, burns)
* Susceptible host

VIRAL INFECTIONS
* Viral exanthems (rashes)
o Exanthem subitum (Roseola Infantum)
+ Rash following a high fever
o Rubella (German measles)
+ Rarely seen because of MMR
+ Important because it can cause serious birth defects
o Measles (Rubeola)
+ Rarely seen because of MMR
+ Occurs with Coryza (rhinitis and sore throat), cough, and conjunctiva
+ Koplik’s spots-whitish spots on the buccal membranes
* Viral exanthems (rashes)
o Chickenpox (Varicella zoster)
+ Will become rare because of mandatory immunization
+ Fluid filled vesicles that crust over, occur in different stages
+ Highly contagious, spread by respiratory droplets as well as contact
o Herpes zoster
+ Same virus as chicken pox but usually occurs in older children/adults
+ Causes painful vesicles along a dermatome
+ May be treated with acyclovir
o Erythema infectiosum (Fifth disease)
+ “slapped cheeks” appearance and a lacy rash
+ Important because it can cause birth defects
o Smallpox (Variola)
+ Important because of bioterrorism
+ People with this are really sick with fever, chills, vomiting, then rash
+ Rash progresses from macule to papule to vesicle to pustule.

VIRAL INFECTIONS
* Enteroviruses
o Coxsackievirus infections
+ Herpangina
o Poliovirus infections: Poliomyelitis
+ Occurs in other parts of the world
+ IPV used now instead of OPV because of immunocompromised people contracting disease shed in stool

Cytomegalovirus

* Common cause of congenital infection in infants
* Some children are asymptomatic for years and then manifest with
o Mental retardation/learning disabilities
o Hearing loss/blindness
* Symptoms evident at birth can include
o Jaundice
o Seizures
o Respiratory distress
o microcephaly
* Therapy is experimental
* Viruses causing central nervous system diseases
o Rabies
* Other viral infections
o Mumps
+ Rarely seen because of MMR
+ Mumps in a teenage or adult man can lead to sterility
o Infectious mononucleosis
+ S/S similar to tonsillitis with sore throat, lymphadenopathy, and fever
+ Spleen is enlarged and fatigue can last ~6 weeks
+ Treat symptoms only

OTHER INFECTIONS
* Scarlet fever
o Group A beta-hemolytic strept
o Often seen with Strept throat
o Usually not seen with “cold” symptoms
o Treated for 10-14 days with antibiotics
* Eye infections/inflammations
o Conjunctivitis (viral or bacterial)
+ Starts in one eye and moves to the other
+ Bacterial…purulent discharge
+ Viral…watery discharge
+ Schools or day care will only believe it is bacterial so treat with antibiotic ointment
+ Highly contagious, can be spread by gnats

OTHER BACTERIAL INFECTIONS

* Anthrax
o Important because of bioterrorism
o Three types, inhalation, cutaneous, & gastro
o Inhalation
+ Most serious, >90% mortality
+ Begins with flu like symptoms
o Cutaneous
+ Begins as a papule and progresses to a painless depressed black eschar
+ Mortality 1% with antibiotic therapy
o Gastrointestinal
+ Acquired by eating undercooked meat infected with anthrax
+ Develops abd. pain, diarrhea; mortality is 25%
o Management
+ Cipro for >18 years, Doxycycline for <18.

* Diphtheria
o S/S
+ Foul nasal discharge, low-grade fever
+ Gray membranes on tonsils and pharynx
+ Neck edema
o Therapeutic management
+ DTaP…rarely seen due to immunization
* Pertussis
o S/S
+ See Box 40-1 pg. 1034
o Therapeutic management
+ DTaP…rarely seen due to immunization
* Lyme disease
o Transmitted by the deer tick
o S/S
+ Papule at the site of the tick progressing to a large swollen ring
+ Systemic involvement
o Therapeutic Management
+ Amoxicillin or PCN V or doxycycline
+ Prevention is the most important tool
* Rickettsial diseases
o Rocky mountain spotted fever
+ Transmitted by the wood, dog, or rabbit tick
+ S/S
# A reddened area develops at the site of the tick bite
# Afterwards, rash, headache, fever, and mental confusion
# CNS involvement
+ Management
# Tetracycline for 7-10 days
# Prevention

OTHER INFECTIOUS PATHOGENS

* Helminthic infections
o Roundworms (Ascariasis)
o Hookworms
o Pinworms

Infectious Disorders.ppt

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Sore Throat

Sore Throat
Presentation by:Richard Usatine, MD

What are causes of sore throats?

* Infectious - viral, bacterial, mycoplasma, chlamydiae, candida
* Allergic - allergic rhinitis
* Acid Reflux - GERD
* Trauma – e.g., swallowing a chicken bone
* Chemical irritants or burns
* Epiglottitis
* Thyroiditis
* Retropharyngeal abscess


Infectious Causes of Pharyngitis
Cause
Strep throat versus viral pharyngitis
Why do we want to diagnose and treat GABHS?
Downside of using antibiotics

Case 1
What is the differential diagnosis in order of likelihood?

* Strep
* Viral
Sensitivity and Specificity
True negative
False negative

False positive
True positive
Positive Predictive Value (PPV)

* Changes based on the prevalence in the population
* True positives/all positives
* Higher prevalence increases the PPV
How well does PE predict strep throat?
Injected Pharynx
Tonsillar Swelling
Tonsillar Exudate
Anterior Cervical adenopathy
Positive Predictive Value
Specificity
Sensitivity
How well does history predict strep throat?
History and Physical
Clinical Prediction Rule for Strep Throat
Fever over 38 C
Absence of cough
Tender ant. cervical adenopathy
Tonsillar swelling or exudate
McIsaac modification of the Centor Criteria
Probability of Strep throat based on points (pretest probability)
How many points does our patient have?
Tender ant. cervical adenopathy
Tonsillar swelling or exudate
What are the tests?
* Rapid strep test
o Done in minutes in the office
* Throat culture
o Gold standard – how can you get false negatives or positives?
* ASO titer – not useful for practicing medicine
How to swab for rapid strep test or culture.
Rapid Strep Test Done
Antibiotic treatment
What symptomatic treatment could you offer the patient?
* Acetaminophen
* gargling with warm salt water
* throat lozenges
* fluids, warm or cold, can be soothing

Case 2
Case 3
Case 4
Case 5
Peritonsillar Abscess
Case 6
Case 7
Strep Throat
Candida in a man with AIDS
Viral
Herpangina
Coxsackie A16 Virus

Summary

* Use of clinical prediction rule to diagnose sore throat (useful in other diseases)
* Clinical prediction rule helps to establish pretest probability and put patient in one of three categories
o No test, no treat
o Test and treat based on result
o No test, just treat
* Use antibiotics for sore throat when probability of strep throat is above your treatment threshold

Sore Throat.ppt

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