Exanthematous Fever

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Exanthematous Fever

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Etiology

• Infectious causes
• Virus
• Classic viral exanthem Measles, Rubella, VZV,
  Parvovirus, Roseola
• Others, HSV, EBV, HBV, Enterovirus, Dengue
• Bacteria Scarlet fever, Staph infection (sepsis,
  4S,toxic shock syndrome), Meningococcemia,
  typhoid
• Mycoplasma
• Rickettsial infection
• Noninfectious cause
• Allergy Food, drug, toxin, serum sickness
• Uncertain cause Kawasaki disease

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Measles

• Measles virus RNA, genus Morbilivirus, family
  Paramyxoviridae
• Airborne transmission
• Winter season
• Only human reservior

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Clinical Manifestation

• Incubation 8-12 days, the average interval
  between appearance of rash in the source case and
  subsequent cases is 14 days, with a range of 7-18
  days.
• Prodromal period fever 2-4 day 3C
• cough
• coryza
• conjunctivitis
• Koplik spot
• Rash erythematous maculopapular rash
• face?sole in 72 hr.
• face and trunk mostly distributed
• pneumonia
• Convalescence
• cough may persist for 1 week

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Diagnosis

• Demographic data
• Hx of contact
• S/S
• 3C, Koplik spot,
• Rash appears before defervescence
• Investigation
• CBC lymphocyte predomination
• serology CF, HI, ELISA
• CXR perihilar peribronchial infiltration

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Complication

• Pneumonia
• Otitis media
• Diarrhea
• Meningoencephalitis
• Croup
• Subacute sclerosing panencephalitis (SSPE)

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Treatment and Care

• Supportive and Symptomatic
• Vit A supplementation
• 6 mo-2 yr hospitalized with measles and
  complication
• gt 6 mo who have risk for severe measles and vit A
  deficiency
• immunodef, vitamin A def, impaired intestinal
  absorption, malnutrition, recent immigration from
  high mortality rated due to measles
• Antibiotic for superimposed bacterial infection

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Treatment and Care

• Isolation Airborne Precaution
• 1-2 day before onset of symptom or 3-5 days
  before onset of rash
• 4 days after onset of rash in healthy children
• For the duration of illness in immunocompromised
  pt.
• Isolated room (negative pressure ventilation)
• Prevention immunization
• 9-15 months
• 4-6 years

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Care of exposed person

• Identify susceptible contact both personnel and
  patient
• immunocompromised patient
• immunocompetent patient who
• lt 6 month old without maternal history of
  measles
• gt 6 month old with unimmunized/unvaccinated
• All exposed susceptible immunocompetent patients
  should be immunized within 72 hr and should be
  discharged as early as possible.
• All susceptible immuocompromised patients should
  received IG 0.5ml.kg IM within 6 days of
  exposure.

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Care of exposed person

• All exposed susceptible patient who cannot be
  discharged should be placed in airborne
  precaution from day 5-21 after exposure.
• All susceptible exposed staff should be excused
  from patient contact from day 5-21 after
  exposure.
• Personnel who become ill should be relieved from
  patient contact for 4 days after rash develops.
• Consider booster dose of MMR in children 4-12
  year who was immunized only 1 dose.

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Care of exposed person
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Rubella

• RNA virus Family Togaviridae, genus Rubivirus
• IP 14-21 days
• Infectivity 7 days before 5 days after onset
  of rash

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Clinical Manifestation

• Prodromal period 1-5 days
• MP rash for lt 3 days
• LN at postauricular and cervical area
• CBC normal range
• Dx viral isolation
• Serologic test CF, HI, IgM ELISA

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Rubella

• Complication
• arthritis
• thrombocytopenia
• meningoencephalitis
• Treatment supportive
• Isolation
• droplet precaution for 7 days after onset of
  rash,
• contact precaution for congenital rubella until gt
  1 yr-old
• Prevention immunization

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Chickenpox

• VZV, HHV-3
• Transmission
• airborne
• contact vesicular fluid
• vertical transmission
• Incubation period
• 14-16 days, (10-21days)
• Infectivity winter season
• Most contagious 1-2 days before onset of rash
  until crusting of lesion.

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Clinical Manifestation

• Prodromal period 2-3 days
• Generalized, pruritic, vesicular rash 250-500
  lesions involving skin and oral mucosa
• Complication
• Herpes Zoster, Shingles
• Congenital varicella Scar, limb, ocular, CNS
  defect
• Bacterial infection
• Severe chickenpox
• CNS encephalitis, cerebellar ataxia, Reyes
  Syndrome

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Diagnosis and Differential Diagnosis

• Diagnosis
• S/S
• Tzanck smear multinucleated giant cell
• Differential Diagnosis
• Impetigo contagiosa
• Enterovirus HFMD
• HSV

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Treatment and care

• Supportive and symptomatic
• antipruritic drug
• for severe case ACV, famciclovir, valacyclovir
• Isolation
• Airborne and contact isolation 1-2 days before
  rash until crusting of all lesion.
• Prevention
• Immunization

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Care of expose Person

• Identify those who are susceptible both personel
  and patient
• immunocompromised patient
• immunocompetent patient who
• lt 6 month old without maternal history of
  chickenpox
• gt 6 month old with unimmunized/unvaccinated
• All exposed susceptible patients should be
  discharged as soon as possible.
• All susceptible patients who cannot be discharged
  should be placed in airborne and contact
  precaution from day 8-21 after exposure.

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• All susceptible exposed staff should be excused
  from patient contact from day 8-21 after
  exposure.
• Varicella immunization is recommended for
  susceptible staff in varicella does not develop
  from the exposure
• Postexposure Immunization 72 (possibly up to)
  120 hr after varicella exposure to prevent or
  significantly modify disease.

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Child Care and School

• Children may return to school when all lesion are
  crusted.
• For compromised children with prolonged course
  should excluded for the duration of the
  vesicular eruption.
• Older children and staff members with zoster
  should be instructed to wash their hands if they
  touch potentially infectious lesion

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Hand-foot-mouth Disease

• coxackie virus type 16 (A 16) most common, other
  include A5, A7, A9, A10, B2, B5(31) and
  enterovirus 71
• Fever, sore throat, drooling
• DDx from Herpes gingivostomatitis
• Self-limited, symptomatic treatment

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HFMD
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Roseola Infantum

• Exanthem subitum
• 3 mo- 3 yr. (6 mo-1 yr)
• HHV-6,7 DNA virus, Herpesviridae
• Uncertain incubation period (9-10 days)

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Clinical Manifestation

• High fever 39-41 c for 3-4 days
• nonspecific symptom
• bulging AF
• febrile convulsion
• MP Rash after defervescence
• CBC normal range of WBC, lymphocyte predominated

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Treatment and Care

• Symptomatic and supportive
• Isolation standard precaution
• Prevention No vaccination

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Erythrema infectiosum (Fifth Dz)

• Parvovirus (PV) B19 Family Parvoviridae
• 3-15 year
• Droplet transmission
• Incubation period 4-14 days
• S/S lowgrade fever, constitutional symptoms,
  arthralgia
• Classical 3 phases
• Sunburn-like rash both cheek (classic
  slapped-cheek appearance) 2-4
• Day 1-4 after facial rash ? macular to
  morbiliform eruption at extremities (extensor
  surface)
• Lacy pattern some w/o classic slapped-cheek
  pattern

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Meningococcemia

• N meningitidis GNDC, bean shape
• Clinical manifestation
• acute febrile illness
• petechiae, hemorrhagic manifestation purpura
  fulminan
• rapid progressive with HT or coma
• meningoencephalitis
• Diagnosis gram stain, antigen detection, buffy
  coat smear and culture
• Treatment penicillin, CTX, CRO

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Guideline for contact case of Meningococci

• Case definition of Invasive Meningococcal Disease
• Confirmed case ve culture for N meningitidis in
  sterile site
• Presumtive ve Gram stain of GPDC in sterile
  site
• Probable ve meningococcal antigen in sterile
  site with compatible clinical manifestation
  (purpura fulminan)
• Clinical manifestation of Invasive meningococcal
  disease acute toxic febrile illness, stiffneck,
  petechiae or purpuric spot with rapidly progress
  to coma, seizure or hypotension

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Indication for Postexposure Prophylaxis

• household contact
• daycare center (same bedroom) within 7 days prior
  to diagnosis
• direct contact to oropharyngeal secretion kiss,
  share toothbrush or eating utensil
• healthcare worker
• Routine nursing care has not increase risk of
  transmission PEP is not indicated.

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Regimen for PEP

• Should begin within 24 hr. after contact.
• Rifampicin 10 mkdose oral bid x 2 day
  (maximumlt600mg)
• Ciprofloxacin 250mg/tab 2 tab single dose
• Cetriaxone 250mg IM (pregnant woman)

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Scarlet fever

• GAS or S aureus pyrogenic exotoxin (SPE)
• Acute febrile illness with
• Sore throat
• Gooseflesh or coarse sand-paper rash within 12-48
  hr.
• Most intense at pressure area axilla, groin
• Pastias line
• Strawberry tongue
• Pustule (Staph scarlet)
• Desquamation begins toward the end of the 1st week

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Scarlet fever
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Scarlet fever
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Scarlet fever
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Staphylococcal scalded skin syndrome (SSSS/4S)

• Staphylococcus toxigenic strain phage group 2
  with epidemolylic toxin A and B
• Start with local infection e.g. purulent
  conjunctivitis, otitis media, nasopharyngeal
  infection
• Fever, MP rash or erythroderma with periorificial
  and flexural accentuation with Nikolski sign

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Impetigo contagiosa
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DHF
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Rose spot in Typhoid Fever
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Thai Tick Typhus
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Kawasaki Disease

• Fever gt 5 days with 4/5 of the following criteria
• bilat nonpurulent conjunctival injection
• Change of mucosa of oropharynx
• Changes of perpheral extremities
• Rash
• Cervical adeonopathy
• Illness not explained by other known disease
  process
• Coronary arteritis

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