FEVER

Fever is defined as elevation of body temp in response to a method pathological armpit stimulus.
oral rectal ear

Celsius >37.3 >37.5 >38 C >38

Maculopapular rash
Papule is a small, solid mostly elevated lesion usually of diameter <0.5 cm. Macule is well circumscribed flat lesion that differ frm surrounding skin cos of their color. Both may have any size,colour and shape. Commonly occur together as maculopapular rash. The commonest presentation, D/D is most difficult may be due to varied spectrum-mild to life threatening, or aetiology. Exanthema-eruption of skin with inflamation Enanthema-eruption of m.m.

Etiological classification
1.Infectious 2.Non infectious 1.Infectious viral: roseola infantum, rubeola, rubella, varicella, erythema infectiosum, EBV, dengue,molluscum contagiosum,echo vs, coxsackie,adenovs.-COMMONEST & most are limited to Pediatric age Bacteria: scarlet fever, syphilis, disseminated gon.

 Fungal:tinea versicolor Others: rocky mountain spotted fever,kawasaki disease. 2.Non infectious: Insect Bites infestations: scabies Drugs Allergies Contact dermatitis

 Potentially life threatening illness with MP rash1.Rubeola 2.Kawasaki dis 3.Rocky mountain spotted fever 4.Dengue fever 5.Erythema multiforme ACUTE ILLNESS,ASSOCIATED WITH FEVER and SIGNIFICANT SYSTEMIC SYMTOMS

Diagnostic approach
1. Proper h/o 2.Past h/o of immunization against measles,rubella etc and past h/o of these illness. 3.Type and Morphological feature of rash. 4.location(primary site) 5.Systemic manifestations.

history
Take history of: Onset of the rash: sudden or gradual. Type of lesion: see Table 35.1. Distribution: whether central, peripheral or generalized. Progression: direction of spread, speed of progression. General well-being of the child, including prodromal

 illness or fever. Infectious contacts. Drug history: including over-the-counter preparations, topical treatments and drugs that have been ceased. Symptoms of the rash: itch, pain, burning. Travel history. Contact with pets and other animals.

Physical examination
Be sure to examine: The entire skin surface:To determine the true extent of the rash. Type of lesions. Distribution. Evolving lesions. The mucous membranes for involvement or ulceration. The conjunctivae for injection or episcleritis.

MP RASH

FEVER | ILL LOOKING

YES

NO
REC CLN APPEARANCE

RECOG CLINICAL APP

YES:ERY MULTIFORME YES:COXSACKIE,FIFTHDIS RUBEOLA SCARLETFEVER,VARICELLA NO:DENGUE NO:DIS GON,EBV,2*SYP KAWASAKI DIS ROSEOLA INFANTUM. RMSF

MEASLES
Most common viral exanthemas(RNA VS). IP is 10-14 days, droplet infection prodromal stage: cough coryza, conjuctivitis,fever.-2-3 days 12-24hrs before the appearance of rash koplik spots will appear on opposite to the molar as pinpoint white lesions on a red base)

 Rash: appears 4-5 days after the prodrome. Rash starts on head(1st behind ear). Spreads downwards to toes.rash disappears after 4-5 days in the same order. Severely malnourished children may develop exfoliation.

MEASELS RASH

 Fever and rash remains for atleast 10 days. May have anorexia and malaise and lymphadenopathy. Rash may be atypical in some-immunized child,even hemorrhagic. Complications:otitis media,laryngitis pneumonia, encephalitis,SSPE, diarrhea, appendicitis, malnutrition, DIC,acute glomerulonephritis. Diagnosis:clinical examination measles specific IgG ELISA heamagglunitation inhibition

 Believed to result frm an immune mediated acute hypersensivity reaction on exposure to antigen: drugs(trimethoprim etc). food(nuts,shell fish) infections. Herpetic and M.pneumoniae infection ranks among the most common cause.

ETIOLOGY
Idiopathic (more than 50 percent of cases) Radiation therapy Medications Penicillin Sulfonamides Phenytoin (Dilantin) Barbiturates Phenylbutazone
Infectious causes Herpes simplex virus Epstein-Barr virus Adenovirus Coxsackievirus B5 Vaccinia virus Mycoplasma species Chlamydia species

Salmonella typhi
Yersinia species

Mycobacterium tuberculosis Histoplasma capsulatum

RASH Erythema multiforme begins as a macular eruption. The dull-red lesions advance from macules that clear from center with prominence of characteristic target-shaped lesions. Vesicles and bullae may develop in the center of the papules. In many patients, the mucous membranes of the mouth and lips are involved.

The illness is classified as minor or major, depending on severity. Erythema multiforme minor-- bullae and systemic symptoms are absent. The eruption is typically confined to the extensor surfaces of extremities and only rarely involves the mucous membranes. Recurrent episodes of erythema multiforme minor usually precede an outbreak of herpes simplex by several days.

 Erythema multiforme major--- most often results from a drug reaction. Mucous membranes are always involved. The eruption tends to become bullous and systemic symptoms, including fever and prostration, are present. Eating may be complicated by cheilitis and stomatitis, and micturition may be difficult because of balanitis and vulvitis. Conjunctivitis may be severe and can lead to keratitis and ulceration. Lesions may also be found in the pharynx, larynx and trachea. Rarely, erythema multiforme major can be lifethreatening and can progress to necrotizing tracheobronchitis, meningitis, blindness, sepsis and renal tubular necrosis.1,4,6

Kawasaki disease
Acute febrile mucocutaneous lymph node syndrome. Cause is unknown,assumed of infectious origin. Vasculitis syndrome-necrotising vasculitis of medium size muscular arteries specially the coronary arteries-Anuresm,dilatation, stenosis >80%-less than 5 years The important aquired cause.

DIAGNOSTIC CRITERIA
A. Fever lasting for atleast 5 days. B. Presence of 4 of the 5 1.b/l non purulent conj. injection 2.changes of mucosae of oropharnyx (injected pharynx, injected lips-red,cracked, strawberry tongue) 3.changes of peripheral extremities (edema, erythema, desquamation) 4.skin rash (truncal, polymorphous but non vesicular)

CONT.

5.cervical lymphadenopathy (atleast 1 node >1.5 cm) C. Illness not explained by any other known disease. Rash is generalized, pruritic with raised erythematous plaques.may be eryth MP rash,morbiliform.may be fleeting and persists for 2-3 days. 20% has coronary artery anerusym,heart failure,valvular dis.

CONT.
Persistent high ESR Marked inc platelet:>750,000mmcub Treatment: IV Ig(2g/kg) aspirin pulse steroids therapy

Caused by Rickettsia rickettsii. Transmitted by bite of tick. Rash begins on day 3-4 of high fever. Rashes are MP type on extremities.most commonly over wrist and ankles. Over next 2 days:becomes generalised and involve back and abdomen.later becomes confluent and purpuric. Notably the rash remains more peripherally distributed with involvement of the palm and soles.

 Pts have some degree of vasculitis. Fever, headache , myalgia, periorbital edema, DIC, seizures, shock, myocarditis and heart failure. Diagnosis:CFT later PCR Treatment: doxycycline

Dengue fever
Acute febrile viral illness presenting with headache,bone or jt or muscular pain rash and leukopenia caused by arthropod virus. A biphasic febrile illness. Dengue hemm fever is characterized by:high grade fever,hgic phenomenon,hepatomegaly and signs of circulatory failure. May develop dengue shock syndrome.

 Appearance of distinct rash coincides with biphasic fever. It is a Generalized,transient,MP rash which blanches under pressure. 24-48 hrs after defervescence a Generalized MP rash appears which spares the palm and soles.

 Diagnosis:raised hematocrit thrombocytopenia positive tourniquet test Treatment: supportive and symptomatic

 Caused by Human parvovirus B19.-5th disease Transmitted by respiratory secretions before the rash appears. IP is 4-14 days. Prodromal illness is minimal. Characteristic lesion occurs in 3 stages. 1st phase:cheeks appears erythematous(slapped cheek)

 2nd phase:itchy erythematous or MP rash appears on trunk and extensors of extremities.palms and soles are spared. 3dr phase:rash fades frm the centre:reticular or lacy pattern. Rash resolves spontaneously but tend to wax and wane can recur with exposure to sunlight,heat, exercise and stress. Complication:arthritis Treatment: IV Ig therapy in immunocompromized children.

Cox sackie vs
Caused by gp A and B-MP rash. Classical with A16 Hand foot and mouth disease. Prodrome:low grade fever,anorexia,mouth pain,malaise. Followed with 1-2 days by an oral exanthema and then a MP rash. Oral lesions begin as small red macules,most often on palate,uvula,ant tonsil pillar-vesiclesulcerates. MP rash may be pruritic and tender.usually on dorsal and lateral aspect of fingers,hands and feet and may be on buttocks.may ulcerate and form scab.

 Complication:aseptic meningitis myopericarditis. encephalitis Treatment:IV Ig if immunocompromized or life threatening infection.

Scarlet fever
By gp A streptococcal infection. Associated with pharyngitis. Fever increases abruptly,may peak at 39.6-40 degree celsius. Rash: genearlized,MP. Skin has sand papery feel on palpation. Sparing of circumoral area-appearance of palor. Bright erythema of tongue, hypertrophy of tongue-strawberry tongue.

 Pastias lines: areas of hyperpigmentation that do not blanch with pressure appear in deep creases. Miliary sudamina(vesicular lesion) may appear on over abdomen, hands and feet.

 Causes infectious mononucleosis. More common in older children. Transmission by intimate contact. also by blood transfusion. IP is 4-5 wks. To begin with fever,malaise,sore throat,anoraxia. Later lymphadenopathy and MP rash appears. MP rash most prominent on trunk and proximal extremities.

 Ulceration in oral cavity. Petechiae at the Jx of hard and soft palate. Splenomegaly and periorbital edema. Frank jaundice in few.

 Diagnosis: lymphocytosis(large and atypical) positive paul bunnel test. demonstration of ant capsid Ag. Treatment: symptomatic Cst acyclovir

Roseola infantum
By herpes simplex VS 6(sixth disease) High fever with pharyngitis. MP rash after 3-4 days of fever. Rash: widely disseminated, discrete, small, pinkish macule on trunk and then extends to extremities. Occurrence of rash after 24 hrs of defervescence rather that the morp appearance of rash is diagnostic.

 By Treponema pallidium. 6-8 wks after primary lesion. Generalized cutaneous eruption: brownish macule or papule. range in size fm few mm to 1 cm.discrete,symmetrical,p articularly over trunk where they follow a line of cleavage..

 Systemic manifestations: malaise,fever,headache.sore throat,rhinnorhoea,lacrimation and gen lymphadenopathy.

 Diagnosis: dark field serology

microscopy

Disseminated N.g
By N.gonorrhea. Seen in a child with s/s of gonn infection:sexually active or abused. With penile or vaginal discharge. Skin lesions: wide range. Small erythematous papule, petechiae, pustule on a hgic base. usually on trunk.

 Diagnosis: gram staining culture frm oral or genital sites

varicella
Early phase. Rash starts as small red macule. Progress to papule and then umblicated vesicle on chest.

Mycoplasma inf
M.pneumoniae. In 15% rash. Classical clinical presentation is a child with malaise, low grade fever and cough.. Persists for 3-4 wks. On X ray diffuse infiltration. Diagnosis: serum cold hemagglutinin. CFT Rx:erythromycin

Drug induced
Abrupt onset. Generalized May be accompanied by systemic signs: fever,arthralgia, hepatosplenomegaly

DISE ASE

IP

PROD ROME

FEV RASH ER

OTHER AGE

SEAS ON

C.P

AGE NT

COMP LICATI ONS

Pneumo nia, death, otitis media, Enceph alitis

measl 718 es
s

Mark hig ed: 2- h day 4 days

5-7 days Cough

, coryza g , conjun older) ctivitis , Koplik spots

1-2d. irritabil widely ity distribut ed small pinkish Macule on trunk, peripher y
27d.gen

7 mos. Winte 45 r years sprin (rarely

2 days Meas before les sympt virus oms throug h first few days

Rose ola Infant um 6th dis

1421 day s

Marke d 3-4 days

hig h

6 mon2yrs

any

unkn own

Hum an Herp es virus 6

no

Scarl et

1-3 day

Marke d

Lo w

pharyn >2yrs gitis

Winte r

Onse t of

Stret gp A

Outbre aks,

DISE ASE

IP

PROD ROME

FEV RASH ER Lo w gra d 2-7d.MP rashvesicles -tender on fingers, hand n feet.

OTHER AGE

SEAS ON any

C.P

AGE NT Cox sacki e gp AnB

COMP LICATI ONS

Aseptic meningi tis Enceph alitis Myopericard itis

Cox sacki e

12d

anore xia, Malias e Fever Mouth pain.o ral Exant hema.

none

unkno wn

Eryth ema infecti osum 5th dis

414 day s

min ima l

2-4d.MP none rash is lace like on arms.wa xn wane.sl apped face appeara nce

Pre puber ty

any

unkn own

Parv o Vs B19

no

DISE ASE

IP

PROD ROME

FEV ER Lo w to hig h

RASH

OTHER AGE

SEAS ON any

C.P

AGE NT T.pal

COMP LICATI ONS

Aseptic meningi tis Enceph alitis Myopericard itis

Sec syphi lis

6-8 wks

Generaliz ed cutaneou s eruption: brownish macule or papule.ra nge in size fm few mm to 1 cm.discre te,symmet rical,parti cularly over trunk where they follow a line of cleavage

malaise ,fever,h eadach e.sore throat,r hinnorh oea,lac rimatio n and gen lympha denopa thy

unkno wn

Drug induc ed

acu te

none

Gen rash

Fever Arthral gia

any

any

none

Life threate ning