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Fever with 
Rash 
By Dr;Walaa Manaa
Types of rash 
Ena.nthem:m.m.rash. Exanthems: skin rash
Macupapuler rash 
Common infection: 
Scarlet fever. 
Measles. 
Geman measles. 
Roseola infantum . 
erythema infectiosum 
E...
Macupapuler rash 
1-rash is essential and 
diag. cannot made with 
out . 
1-common inf. 
(scarlet-measles-g. 
measles-ros....
Fever with rash: 
• May indicate a serious bacterial 
infection in 20% of cases 
(e.g.menengococcal 
menengitis,HIb,,,,,,,...
Fever with rash: 
1-very  (varecilla) chicken pox & menigitis. 
2-Sick  scarlet fever & erysipelas. 
3-People  small po...
Dangerous sings in 
fever with rash: 
1-if associated with 
sever constitutional 
S&S. 
2-if hemorrhagic. 
3-if is extensi...
clinical history 
1-personal data 
(Age-Gender-Ethnicity-Season- 
Geographic area) 
2-Exposures 
contacts (home, day care…...
4-Features of rash 
(onset relative to fever-Progression- 
Location- distribution Pain or pruritus) 
5-Past history 
(Medi...
clinical examination 
1-Degree of toxicity 
2- Characteristics of rash 
(Macular-Papular-Maculo papular Petechiae or purpu...
Viruses Bacteria Other 
Maculo/papul 
ar rash 
Measles, rubella, 
HHV-6 
EBV, HBV, HIV, 
enterovirus 
GABHS (scarlet 
feve...
Case presentation
History: 
9 mo old girl, good general health condition 
Progressive fever for 3 days (max. 39.5 C) 
Coryza, exudative conj...
Measles 
Acute viral infection 
Human being is the only reservoir 
Caused by a paramyxovirus 
Very contagious (reach 90% o...
Rubeola. 
*Viral disease. 
*I.P. 2W 
*Age >6-9 ms?? 
*fever: 
rises gradually in 1st 4dayes reach 40 with apperarace of ra...
The rash starts behind the ears and on 
the forehead at the hair line 
• The spread of the rash is centrifugal 
(head to l...
Diagnosis 
Clinical 
Serology PCR V iral culture
Characteristic features: 
Koplik s spotes; 
*Appeare 3rd day.i.e.one day before the rash. 
*White grains of sand surrounde...
complications 
(more severe in adults) 
1-pneumonia (viral or commonly 2nd bacterial)50%. 
2-encephalitis 
1-accompany the...
Treatment 
*No specific antiviral treatment. 
*Vaccination within 72h after contact. 
*Immunoglobulins within 6 days after...
Important notice … 
*Eradication of measles can be obtained if >95% of the 
population is immune. 
*Measles is endemic if ...
• - يمكن ان تأتى الحصبة بدون التهاب بالعينين لكن لا يمكن ان تأتى بدون كحة 
لان الفيروس موجود فى الحلق 
• - فيروس الحصبة مو...
- مريض الحصبة عرضة لمشاكل بالعينين قد تؤدى للعمى لذلك لابد من غسل العينين 
بالماء وبمحلول ملحى بصفة متكررة ووضع مرهم مضاد ...
• مريض الحصبة عرضة للاصابة بالجفاف فى حالات الاسهال 
)كمضاعفات( لذلك ينصح بالاكثار من السوائل والتغذية الجيدة 
ومحلول معال...
- خلى بالك 
pneumonia : لو عيان عنده حصبة وبينهج 
encephalitis or febrile convulsion : لو طفل عنده حصبة وبيتشنج 
dehydrati...
• الحصبة تضعف المناعة مؤقتا لمدة 6 اسابيع بعد العدوى 
measles virus suppresses cell mediated immunity 
• - طبعا ممنوع استع...
فيه 3 اسئلة 
السؤال الاول : من هو المريض الذى يتحسن نتيجة اصابته بالحصبة وما هو 
المريض الذى تسؤ حالته نتيجة اصابته بالحصب...
اجابة السؤال الاول : المرض الذى يسؤ مع الحصبة هو الدرن , الحصبة تضعف المناعة فتؤدى الى 
minimal change nephrotic المرض الذ...
Clinical case #2 
History: 
7 y. old boy, good general health condition 
Sudden onset of sore throat since 24h and 
fever ...
Scarlet fever - Scarlatina 
Scarlatina is caused by erythrogenic 
exotoxin producing strains of 
Group A ß-hemolytic Strep...
Clinical features 
*Abrupt onset 
*Fever—39 C 
*Sore throat 
*Abdominal pain 
*Variable pharyngitis 
*Tender lymphadenopat...
Rash: 
Appears in1st or 2nd day 
Soon become generalized 
(gooseflesh=sandpaper) 
Flushed face+cicumoral pallor 
Remaine3-...
Thick, white layer through 
which red papillae protrude 
(white strawberry tongue) 
Peeling after several days 
(red straw...
After a week, the rash 
typically starts to 
desquamate, 
particularly on the 
hands and feet
Complications of GAS infection 
Local: Otitis media 
Pharyngeal abcess 
Adenitis 
Invasive: Sepsis 
Non suppurative: 
Glom...
Diagnosis: Clinical 
Rapid strep test 
Culture 
ASLO 
Treatment: Antibiotics 
(penicillin)
Clinical case #3 
A 15-month-old child presents to 
your office 
with a mild fever, and an intense, red 
rash on the cheek...
« Slapped cheek disease » 
fifth disease, erythema infectiosum 
Caused by Parvovirus B19 
Discovered in 1975 
Causes sprin...
I.P……………..4-14 days 
Stage I 
Mild prodromal illness 
low grade fever 
headache 
GI symptoms 
Stage II (+3-7 days) 
Erythe...
Children are infectious during the prodromal stage and 
do not shed virus at the time of the rash anymore 
===Control of e...
Complications of 
parvovirus B19 
1-Erythrocyte aplasia 
(by direct infection of the red cell 
precursors) 
2-Intrauterine...
Diagnosis 
Clinical 
Serology (arthritis, 
red cell 
aplasia..) 
Treatment 
No specific treatment 
Parvovirus B19
Clinical case #4 
History: 
6 month old boy, 
No past medical history 
No prodromes 
Fever 40 C of sudden 
onset Febrile c...
Roseola infantum, 
exanthem subitum 
« sixth disease » 
Caused by Human herpes virus type 6 (HHV-6B) in rare 
cases by HHV...
Clinical manifestations 
Often asymptomatic 
Mild prodromes (rhinorrhea, diarrhea) 
Sudden onset of fever (39-40C) lasting...
Diagnosis 
• Clinical 
• Serology 
• PCR 
Treatment 
• Symptomatic (antipyretics)
Clinical case #5 
History: 
5 y old boy, no special past 
medical history 
Low grade fever (38.30C) for 48 h 
Attends scho...
A7-year-old unimmunized child presents with fever 
and vesicular rash. You notice about 300 
lesions, some of which were c...
(E) The rash of varicella follows an incubation 
period of 10–21 days. There is the onset of a very pruritic 
rash, with c...
Caused by varicella/zoster virus 
Most common exanthematous disease of 
childhood 
Humans are the only reservoir 
Affects ...
Occurs in late winter early spring 
Less common in tropical climates 
Incubation period 14 days (10-21) 
Replication at th...
Prodromes with 1-2 days of 
low grade fever 
• Erythematous papules 
• Vesicules 
• Pustules 
• Crust 
Spread from the tru...
Diagnosis 
• Clinical 
• Serology 
• Immunofluorescence 
• Culture 
• PCR
Complications 
Increase with age 
1-Pneumonia 
Rare in children, high mortality in 
immunocompromised host) 
2-Cerebellar ...
5-Superinfections 
locally with S. aureus or 
GABHS cellulitis 
systemic with GABHS 
sepsis, necrotizing fasceitis 
Strep...
Complications 
7-conginital infection 
(2%, 18-22 w of gestation) 
Small size, cutaneous scarring, limb 
hyplasia, microce...
Treatment
Secondary prevention 
Must be administered by 96h after exposure (or better if < 72h) 
Primary and secondary prevention by...
Clinical case #6 
You are counseling a primigravid woman 
who has been found to be rubella non 
immune on prenatal laborat...
(A) Congenital malformations, stillborns, and abortions 
all have been reported with rubella infection during 
pregnancy. ...
German measles 
*Viral disease 
*IP……2-3 W 
*Fever: 
Mild remain for 1-2 day it may absent ( cold 
measles) 
*Rash: 
Start...
Complication: 
1-Usually absent in children. 
2-Congenital rubella synd(cataract+CHD)
Clinical case #7 
An 18-year-old boy presents with acute severe 
chest pain. EKG and enzyme studies confirm 
an acute myoc...
History: 
20 mo old boy 
High fever (39.50C) for 5 days 
remittent with several spikes each day 
Irritable 
No cough 
Phys...
First described in 1967 
Incidence: 67 cases /100’000 in Japan 
5.6 cases/100’000 in the USA 
KAWASAKI 
85% in children < ...
92% 
65% 
75%
More than 5 days 
Non purulent
77%
Associated findings 
Aseptic meningitis (25%) 
Arthritis and arthralgia (20-40%) 
Diarrhoea 
Hydrops of the gallbladder 
L...
Complications 
Coronary aneuvrysm 
Prognosis 
75% no sequelae, 25% coronary abnormality 
(without treatment), 
1-2% mortal...
Treatment 
1-Immunoglobulins 2g/kg 
body weight. 
2-Aspirin 80-100 
mg/kg/day during 
the acute phase 
then 3-5 mg/kg/day ...
Clinical case #8 
A13-year-old female presents to the emergency 
department with a 3-day history of fever above (40°C); 
v...
(B) Manifestations of staphylococcal toxic shock syndrome, which 
include fever, mental status changes, conjunctivitis,dif...
Clinical case #9
Allergic skin 
disease
1-Miliaria
-Common inflammatory diseases .* 
-Sweet duct obstructions. 
-Hot weather. 
-fine papule with intense erythema, 
vesiculat...
2-Drug rash
3-Urticarial rash 
Wheals +itchy
4-papular urticaria 
-Delayed hyper sensitivity reaction 
to insect bite fleas +mosquitoes. 
-Face and scalp are spared . ...
Erythema multiformis 
Is hypersensitivity reaction to varities of causes (drugs-infection-toxins ). 
erythema multiforme m...
erythema multiforme major 
Stevens-Johnson syndrom 
*Serious form affecting skin and m.m. 
*Start sudden by fever chills 
...
1 skin rash
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1 skin rash

  1. 1. Fever with Rash By Dr;Walaa Manaa
  2. 2. Types of rash Ena.nthem:m.m.rash. Exanthems: skin rash
  3. 3. Macupapuler rash Common infection: Scarlet fever. Measles. Geman measles. Roseola infantum . erythema infectiosum Enteroviral infection. Skin and allergic condition Sweat rash Drug rash. uticarial rash Papuler urticaria Erythema multiformie Vesiculer rash Common infection Chickenpox Herpes simplex Herpex zoster Skin and allergic condition: Papuler urticaria Impitigo contangiosa Erythema multiformis
  4. 4. Macupapuler rash 1-rash is essential and diag. cannot made with out . 1-common inf. (scarlet-measles-g. measles-ros.infuntum-eryth. inf.-rota virus inf.) 2-skin and allergic cond; (sweat rash- drug rash urticarial rash-papuler urticaria-erythema multi forme 1-rash is not essential and diag. can made with out . 1-Infection (typhoid-IMN-ricketttsial disease. 2-rheumatic diseases (JRA-SLE-Kawasaki)
  5. 5. Fever with rash: • May indicate a serious bacterial infection in 20% of cases (e.g.menengococcal menengitis,HIb,,,,,,,,,) • 80% of cases are caused by viral infection.
  6. 6. Fever with rash: 1-very  (varecilla) chicken pox & menigitis. 2-Sick  scarlet fever & erysipelas. 3-People  small pox. 4-Must  measles. 5-Take  typhus. 6-Entire  enterica. 7-good  glandular fever. 8-Rest  relapsing fever.
  7. 7. Dangerous sings in fever with rash: 1-if associated with sever constitutional S&S. 2-if hemorrhagic. 3-if is extensive. 4- if associated with shock or coma.
  8. 8. clinical history 1-personal data (Age-Gender-Ethnicity-Season- Geographic area) 2-Exposures contacts (home, day care…) Travel, Pets, insects ,drugs ,Immunization 3- Associated symptoms Focal (suggesting organ) Systemic (multisystem illness).
  9. 9. 4-Features of rash (onset relative to fever-Progression- Location- distribution Pain or pruritus) 5-Past history (Medical and surgical history-Growth and development Recurrent infectious illnesses) 6-Family history.
  10. 10. clinical examination 1-Degree of toxicity 2- Characteristics of rash (Macular-Papular-Maculo papular Petechiae or purpura) Vesicles, pustules, bullae Nodules. Diffuse/localized erythroderma. 3-Associated enanthem Buccal and genital mucosa Palate Pharynx and tonsils 4- Associated findings Arthritis, ocular, GI, cardiac…
  11. 11. Viruses Bacteria Other Maculo/papul ar rash Measles, rubella, HHV-6 EBV, HBV, HIV, enterovirus GABHS (scarlet fever)… Salmonella, Lyme, Mycoplasma pneumoniae Rickettsia Vesicular, bullous VZV, HSV, Echovirus Coxsackievirus A, B Impetigo Petechial CMV, enterovirus, EBV Hemorrhagic fever, VZV Sepsis (N.men, S.pneu,Hib) Rat bite fever (S. minus) Rickettsia Diffuse erythroderma Dengue scarlet fever, TSS C. albicans Urticarial rash EBV, HBV, HIV, Enterovirus M. pneumoniae
  12. 12. Case presentation
  13. 13. History: 9 mo old girl, good general health condition Progressive fever for 3 days (max. 39.5 C) Coryza, exudative conjontivitis, severe cough and irritability No diarrhea, no vomiting No recent travel, no pets Attends day care 2d/w Confluent maculo-papular rash all over the body
  14. 14. Measles Acute viral infection Human being is the only reservoir Caused by a paramyxovirus Very contagious (reach 90% of susceptible contacts within a family. Respiratory route)
  15. 15. Rubeola. *Viral disease. *I.P. 2W *Age >6-9 ms?? *fever: rises gradually in 1st 4dayes reach 40 with apperarace of rash. Then after 2days decline to normal ( after rash reach to feet). Fever associated sevse catarrhal manifest.(rhinitis—conjuctivitis— cough). No measles with out cough.
  16. 16. The rash starts behind the ears and on the forehead at the hair line • The spread of the rash is centrifugal (head to legs)
  17. 17. Diagnosis Clinical Serology PCR V iral culture
  18. 18. Characteristic features: Koplik s spotes; *Appeare 3rd day.i.e.one day before the rash. *White grains of sand surrounded by red areola . *On oral mucosa oppositeto the lower molar teeth. *Remain 1-2 days . *Disappear after onset of rash.
  19. 19. complications (more severe in adults) 1-pneumonia (viral or commonly 2nd bacterial)50%. 2-encephalitis 1-accompany the illness(viral encphalitis. 2-2-3 weeks after the illness (allergic enchelalitis). 3-Several years later (SSPE). 3-Black measles (purpuric rash+hgic manifestation.) 4- Myocarditis and pericarditis 5-Acute otitis media (10-15%) .
  20. 20. Treatment *No specific antiviral treatment. *Vaccination within 72h after contact. *Immunoglobulins within 6 days after contact in immunocompromised and < 1 y old children.
  21. 21. Important notice … *Eradication of measles can be obtained if >95% of the population is immune. *Measles is endemic if 15-20% of the population is susceptible *Epidemics can occur if > 25% of the population is susceptible (without fear, vaccinate your children) « No evidence for measles, mumps, and rubella vaccine-associated inflammatory bowel disease or autism in a 14-y prospective study » et al. Lancet 1998
  22. 22. • - يمكن ان تأتى الحصبة بدون التهاب بالعينين لكن لا يمكن ان تأتى بدون كحة لان الفيروس موجود فى الحلق • - فيروس الحصبة موجود بالإفرازات الانفية والحلق لذلك ينصح باستعمال نقط محلول ملح بالانف
  23. 23. - مريض الحصبة عرضة لمشاكل بالعينين قد تؤدى للعمى لذلك لابد من غسل العينين بالماء وبمحلول ملحى بصفة متكررة ووضع مرهم مضاد حيوى مرتين يوميا لمدة 5 ايام وتنصح وزارة الصحة باعطاء فيتامين أ لمرضى الحصبة لما له من دور هام فى الحماية من مشاكل العينين وايضا يقلل نسبة الوفاة من الحصبة الى 50 % والجرعات كالاتى اقل من 6 شهور 50,000 وحدة يوميا لمدة يومين من 6 شهور : سنة : 100,000 وحدة يوميا لمدة يومين اكبر من سنة : 200,000 وحدة يوميا لمدة يومين فى المرضى اللى عندهم اعراض نقص فيتامين أ كجفاف الجلد و .. يتم اعطائهم جرعة 4 اسابيع - ثالثة بعد 2
  24. 24. • مريض الحصبة عرضة للاصابة بالجفاف فى حالات الاسهال )كمضاعفات( لذلك ينصح بالاكثار من السوائل والتغذية الجيدة ومحلول معالجة الجفاف ومحاليل بالوريد عند الضرورة • - مريض الحصبة معرض لفطريات الفم وقرح الفم : دكتارين جل + بى بى سى بخاخ .
  25. 25. - خلى بالك pneumonia : لو عيان عنده حصبة وبينهج encephalitis or febrile convulsion : لو طفل عنده حصبة وبيتشنج dehydration or encephalitis : لو عيان عنده حصبة ومدروخ otitis media : لو طفل عنده حصبة ومش مبطل عياط appendicitis (right iliac : لو عيان عنده حصبة وجاله الم شديد بالبطن )fossa subacute sclerosis : لو شخص عمره حوالى 30 سنة وجاله الزهايمر pan encephalitis لو عيان عنده الحصبة وفقد البصر يبقى انت السبب عشان ما اهتمتش بالعينين وما اديتش فيتامين أ
  26. 26. • الحصبة تضعف المناعة مؤقتا لمدة 6 اسابيع بعد العدوى measles virus suppresses cell mediated immunity • - طبعا ممنوع استعمال الاسبرين كخافض للحرارة عشان راى سيندروم 2ry bacterial infection • - ولازم نستخدم مضادات حيوية عشان نمنع • - الالتهاب الرئوى كمضاعفات للحصبة قد يكون سببه فيروس الحصبة نفسه 2ry bacterial pneumonia أو قد يكون سببه بكتيرى sibilant الفرق ما بينهم ان الالتهاب الرئوى الفيروسى معاه تزييق بالصدر rhonchi انما الالتهاب الرئوى البكتيرى عمره ما يعمل تزييق بالصدر
  27. 27. فيه 3 اسئلة السؤال الاول : من هو المريض الذى يتحسن نتيجة اصابته بالحصبة وما هو المريض الذى تسؤ حالته نتيجة اصابته بالحصبة؟ السؤال الثانى : كيف تعالج الالتهاب الرئوى والالتهاب السحائى الناتج عن الحصبة؟ السؤال الثالث: من المعروف ان الحصبة تضعف المناعة لمدة 6 اسابيع فهل خلال live attenuated vaccines يمنع الاطفال من تطعيم شلل الاطفال و تلك الفترة
  28. 28. اجابة السؤال الاول : المرض الذى يسؤ مع الحصبة هو الدرن , الحصبة تضعف المناعة فتؤدى الى minimal change nephrotic المرض الذى يتحسن مع الحصبة هو activation of TB syndrome treatment of measles pneumonia and encephalitis is اجابة السؤال الثانى mainly symptomatic with addition of antibiotics to prevent secondary تم تجربة الريبافيرين فى هذه الحالات وثبت انه فعال جدا ضد فيروس bacterial infection الحصبة لكن لم يعتمد بعد من منظمة الصحة العالمية measles not contraindication to live attenuated vaccines اجابة السؤال الثالث but it is recommended to delay vaccination untill the acute febrile illness ceased severe immunuodifieciency is absolute contraindication to live attenuated vaccines
  29. 29. Clinical case #2 History: 7 y. old boy, good general health condition Sudden onset of sore throat since 24h and fever at 39C. Abdominal pain and 1 episode of vomiting No conjuntivitis, No rhinitis, No hoarseness No cough Attends primary school, no recent travel
  30. 30. Scarlet fever - Scarlatina Scarlatina is caused by erythrogenic exotoxin producing strains of Group A ß-hemolytic Streptococci Common among school-age children (very unsual in < 2 y old) 5-10% of healthy carriers Transmission by direct contact or respiratory droplets Incubation: 2 to 5 days Untreated cases remain infectious for a prolonged period, unlikely after 24h of appropriate antibiotic therapy
  31. 31. Clinical features *Abrupt onset *Fever—39 C *Sore throat *Abdominal pain *Variable pharyngitis *Tender lymphadenopathy
  32. 32. Rash: Appears in1st or 2nd day Soon become generalized (gooseflesh=sandpaper) Flushed face+cicumoral pallor Remaine3-7 day Fade with branny desquamation Usually involves palms and soles
  33. 33. Thick, white layer through which red papillae protrude (white strawberry tongue) Peeling after several days (red strawberry tongue)
  34. 34. After a week, the rash typically starts to desquamate, particularly on the hands and feet
  35. 35. Complications of GAS infection Local: Otitis media Pharyngeal abcess Adenitis Invasive: Sepsis Non suppurative: Glomerulonephritis rheumatic fever erythema nodosum
  36. 36. Diagnosis: Clinical Rapid strep test Culture ASLO Treatment: Antibiotics (penicillin)
  37. 37. Clinical case #3 A 15-month-old child presents to your office with a mild fever, and an intense, red rash on the cheeks with circumoral pallor. What is the most likely etiology of this febrile exanthem? (A) enterovirus 71 (B) adenovirus (C) parvovirus B19 (D) rubeola virus (E) coxsackievirus A16
  38. 38. « Slapped cheek disease » fifth disease, erythema infectiosum Caused by Parvovirus B19 Discovered in 1975 Causes spring epidemics in children 4-10y (attack rate 40%) Often asymptomatic - soSeroprevalence of 50% at age 15
  39. 39. I.P……………..4-14 days Stage I Mild prodromal illness low grade fever headache GI symptoms Stage II (+3-7 days) Erythematous facial exanthem (slapped cheeks ) Stage III (+1-4 days) Lacy maculo-papular exanthem on the trunk and extremities. May be pruritic, evanescent, Arthropathy (adults >> children, female >> male
  40. 40. Children are infectious during the prodromal stage and do not shed virus at the time of the rash anymore ===Control of epidemics very difficult
  41. 41. Complications of parvovirus B19 1-Erythrocyte aplasia (by direct infection of the red cell precursors) 2-Intrauterine infection (hydrops fetalis (5% of infected foetus), rash, hepatomegaly, cardiomegaly and anemia)
  42. 42. Diagnosis Clinical Serology (arthritis, red cell aplasia..) Treatment No specific treatment Parvovirus B19
  43. 43. Clinical case #4 History: 6 month old boy, No past medical history No prodromes Fever 40 C of sudden onset Febrile convulsion 3 days later the fever abates and widespread macular rash
  44. 44. Roseola infantum, exanthem subitum « sixth disease » Caused by Human herpes virus type 6 (HHV-6B) in rare cases by HHV-7 Discovered in 1988 >95 % of children are affected Almost all cases between 4 mo and 2 years Sporadic illness (rare outbreaks) No seasonal distribution Reactivation possible (immunosuppressed persons)
  45. 45. Clinical manifestations Often asymptomatic Mild prodromes (rhinorrhea, diarrhea) Sudden onset of fever (39-40C) lasting 3-5 days Rose-coloured macular rash, present for few hours up to 2days Affects the neck and trunk extending to the face and proximal extremities No pruritus, no desquamation Associated with febrile convulsion
  46. 46. Diagnosis • Clinical • Serology • PCR Treatment • Symptomatic (antipyretics)
  47. 47. Clinical case #5 History: 5 y old boy, no special past medical history Low grade fever (38.30C) for 48 h Attends school No travel history No pets Vesicular rash on the trunk and face
  48. 48. A7-year-old unimmunized child presents with fever and vesicular rash. You notice about 300 lesions, some of which were crusted. You suspect varicella infection. Which of the following is a TRUE statement about varicella? (A) It has an incubation period of 5–7 days. (B) The rash is confluent, centrifugal, and pustular. (C) It is associated with Koplik spots. (D) There is a high risk of shingles. (E) It can cause visceral dissemination in the immunocompromised host.
  49. 49. (E) The rash of varicella follows an incubation period of 10–21 days. There is the onset of a very pruritic rash, with crops of lesions that begin as papules and progress to vesicles and finally crusted scabs. Typically, all three stages of skin lesions are identified on clinical examination. Fever usually is mild to moderate. While a generally self-limited and benign course is noted, severe disease may occur occasionally in the otherwise healthy host, especially adolescents and adults. A progressive and severe disease with visceral dissemination is seen in 30%–50% of children with lymphoproliferative malignancies, solid tumors, or posttransplantation with the development of hepatitis, encephalitis, and pneumonia. Fatal disease has also been reported in those treated with highdose corticosteroids and in those with other defects of T-cell function. (Long, 1022– 1024
  50. 50. Caused by varicella/zoster virus Most common exanthematous disease of childhood Humans are the only reservoir Affects 90% of children between 1 to 14 years Highly contagious (>90% in household contacts) Contagiosity: 2 days before to 5 days after the rash
  51. 51. Occurs in late winter early spring Less common in tropical climates Incubation period 14 days (10-21) Replication at the site of infection, primary viremia which establishes replication in the reticulo endothelial system. A secondary viremia occurs after about a week with disseminates to the skin.Establishment of latency in sensory ganglia reactivates years later to cause zoster
  52. 52. Prodromes with 1-2 days of low grade fever • Erythematous papules • Vesicules • Pustules • Crust Spread from the trunk to the face, neck and extremities Pruritus +++ Mucous membranes can be Involved The hall mark of the varicella rash is the simultaneous presence of lesions of different stages
  53. 53. Diagnosis • Clinical • Serology • Immunofluorescence • Culture • PCR
  54. 54. Complications Increase with age 1-Pneumonia Rare in children, high mortality in immunocompromised host) 2-Cerebellar ataxia (1/4000 in <15 y) Develops 7 to 10 days into the disease,excellent prognosis 3- Transvere myelitis, Guillain-Barre sy. 4- Hemorrhagic varicella Thrombocytopenia
  55. 55. 5-Superinfections locally with S. aureus or GABHS cellulitis systemic with GABHS sepsis, necrotizing fasceitis Strep. TSS 6-Reye syndrome Persistant vomiting, decreasing mental status, liver failure. Associated with salicylate-containing products Avoid aspirin in varicella !!!
  56. 56. Complications 7-conginital infection (2%, 18-22 w of gestation) Small size, cutaneous scarring, limb hyplasia, microcephaly, cortical atrophy, chorioretinitis, cataracts …. 8-Perinatal infection 5 days before to 2 days after birth (high mortality without treatment 30%)
  57. 57. Treatment
  58. 58. Secondary prevention Must be administered by 96h after exposure (or better if < 72h) Primary and secondary prevention by a vaccine
  59. 59. Clinical case #6 You are counseling a primigravid woman who has been found to be rubella non immune on prenatal laboratorye valuation. She asks you if her fetus is at risk for malformations. When is maternal infection with rubella virus most commonly associated with congenital defects? (A) in the first 4 weeks of gestation (B) in the second month (C) in the third or fourth month (D) in the last trimester (E) anytime during pregnancy
  60. 60. (A) Congenital malformations, stillborns, and abortions all have been reported with rubella infection during pregnancy. The congenital rubella syndrome consists of ophthalmologic, cardiac, auditory, and neurologic abnormalities with rates as high as 85% if infection occurs in the first 4 weeks of gestation, decreasing to 20%–30% during the second month, and 5% during the third or fourth month. These infants may continue to excrete rubella virus for 1 year or more after birth and pose a risk of infection for susceptible hosts. (American Academy of Pediatrics, 574)
  61. 61. German measles *Viral disease *IP……2-3 W *Fever: Mild remain for 1-2 day it may absent ( cold measles) *Rash: Start in 2nd -3rd day on face----spread to trunk rapidly cover all body in 24 hrs Clear completely in 3 days *Characteristic sign Post auriculer –occipital-post cx LN
  62. 62. Complication: 1-Usually absent in children. 2-Congenital rubella synd(cataract+CHD)
  63. 63. Clinical case #7 An 18-year-old boy presents with acute severe chest pain. EKG and enzyme studies confirm an acute myocardial infarction. Cardiac catherization reveals a coronary artery aneurysm with thrombosis. Which constellation of symptoms in his past could explain this finding? (A) conjunctivitis, fever, cervical lymphadenopathy (B) meningitis, conjunctivitis, pallor (C) cervical lymphadenopathy, hepatitis, rash (D) fever, irritability, pancreatitis (E) hepatosplenomegaly, rash, conjunctivitis
  64. 64. History: 20 mo old boy High fever (39.50C) for 5 days remittent with several spikes each day Irritable No cough Physical examination Bad general condition Polymorphous rash conjunctival injection fissured lips cervical lymphadenopathy (>1.5 cm) No travel history No pets Vaccination: OK for the age
  65. 65. First described in 1967 Incidence: 67 cases /100’000 in Japan 5.6 cases/100’000 in the USA KAWASAKI 85% in children < 5 years (peak 18-24 mo) Rarely occurs in adolescent, adults or children < 6 mo M/F ratio 1.4:1 Occurs often in late winter and spring Etiology: UKNOWN Pathophysiology: « Superantigen theory » causing an intense vasculitis disease VASCULITIS
  66. 66. 92% 65% 75%
  67. 67. More than 5 days Non purulent
  68. 68. 77%
  69. 69. Associated findings Aseptic meningitis (25%) Arthritis and arthralgia (20-40%) Diarrhoea Hydrops of the gallbladder Laboratory High ESR and CRP Sterile pyuria High platelet count (second week) Differential diagnosis Measles, scarlet fever TSS, Steven-Johnson sy, Juvenile rheumatoid arthritis… 4
  70. 70. Complications Coronary aneuvrysm Prognosis 75% no sequelae, 25% coronary abnormality (without treatment), 1-2% mortality in the acute phase
  71. 71. Treatment 1-Immunoglobulins 2g/kg body weight. 2-Aspirin 80-100 mg/kg/day during the acute phase then 3-5 mg/kg/day for months when fever subsides
  72. 72. Clinical case #8 A13-year-old female presents to the emergency department with a 3-day history of fever above (40°C); vomiting; diarrhea; and diffuse erythematous rash. She is found to have orthostatic hypotension. Laboratory evaluation reveals decreased platelets and elevated liver and renal function tests. The mother of the child informs you that the child is currently menstruating. You suspect that this child has a toxin mediated infection. What is the most likely etiology of this toxin mediated infection? (A) Streptococcus pyogenes (B) Staphylococcus aureus (C) Neisseria gonorrhoeae (D) Streptococcus agalactiae (E) Shiga-toxin-producing Escherichia coli
  73. 73. (B) Manifestations of staphylococcal toxic shock syndrome, which include fever, mental status changes, conjunctivitis,diffuse macular erythroderma, and multiple organ failure, are caused by a toxin elaborated by the staphylococci rather than by tissue invasion of the organism. The name of the toxin is toxic shock syndrome toxin- 1(TSST-1), and is produced by S aureus. The organism usually can be cultured from skin or mucous membrane and only rarely from the blood. It has been recovered from the vagina and has been associated with the use of tampons, especially those designed to be changed infrequently. Streptococcal toxic shock syndrome is cause by S pyogenes (group Astreptococcus). The incidence is highest among young children, particularly those with concomitant varicella. The organism can be isolated from blood about 50% of the time. Both N gonorrhoeae and S agalactiae can be found in the genital tract (the former as a pathogen and the latter as normal flora); neither is associated with toxin-mediated disease. Shiga toxin produced by E coli causes diarrhea and can be associated with hemolytic uremic syndrome. (Long, 110–112; American Academy of Pediatrics, 660–661)
  74. 74. Clinical case #9
  75. 75. Allergic skin disease
  76. 76. 1-Miliaria
  77. 77. -Common inflammatory diseases .* -Sweet duct obstructions. -Hot weather. -fine papule with intense erythema, vesiculation may occur(miliaria crystallina). -Ttt ----cooling + removal of excessive clothes.
  78. 78. 2-Drug rash
  79. 79. 3-Urticarial rash Wheals +itchy
  80. 80. 4-papular urticaria -Delayed hyper sensitivity reaction to insect bite fleas +mosquitoes. -Face and scalp are spared . -Itchy. -DD with scabis.
  81. 81. Erythema multiformis Is hypersensitivity reaction to varities of causes (drugs-infection-toxins ). erythema multiforme minor *skin only. *extensor surface of extremities .Appear in croops in up to 3 weeks. Palm and sole are affected. * pathognomonic --targit lesion *not itchy Heal with pigmentation (hypo or hyper)
  82. 82. erythema multiforme major Stevens-Johnson syndrom *Serious form affecting skin and m.m. *Start sudden by fever chills *Dominant lesion bullous at skin and m.m.upturehealing in 1-4- w. *Oral lesions are painful. *Ocular lesions serios complicatios. *2ndry bacterial infection may result in seticemia and death.

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