Fever with Rash

Infectious Diseases & Tropical Pediatrics Division

Department of Pediatrics
Faculty of Medicine
University of North Sumatera
Medan, Indonesia
 Introduction
Skin rashes or exanthems are among the
most common clinical presentation in
childhood.

They are associated with diseases ranging

from benign self-limiting illnesses caused by
viruses to severe life-threatening bacterial
infection.
 The etiology of exanthem disease can be
differentiated by:

1. History of previous infectious disease and

immunization

2. Manifestation of the prodromal symptoms

3. Characteristics of the rash (location and

distribution)

4. Patognomonic sign

5. Laboratorium
Etiology of different type of rash

Maculopapular Papulovesicular
Measles Varicela-zoster
Rubella Variola
Scarlatina fever Eczema herpeticum
Staphylococcal scalded skin Coxsackie
syndrome Impetigo
Staphylococcal toxix shock Insect bite
syndrome Steven johnson syndrome
Meningococcemia
Toxoplasmosis
Cytomegalovirus
Roseola infantum
Enterovirus
Mononucleosis
Drug reaction
 Maculopapular Rash
Disease Etiology/ Patogno Prodrome Rash distribution Lymphadenop
Incubation monic athy
period
Measles Morbilivirus Koplik Fever, cough, Begins when fever peak, (+)
10-12 days spot conjunctivitis and rash spreading down
coryza from the face and
hairline to the trunk over
3 days and later
becoming confluent

Roseola HHV 6 (-) Rose-pink Coincides with lysis of (+)

infantum 10-15 days maculopapular rash fever, begins on the
appears when fever trunk and spreads to the Cervical,
subsides. face, neck and posterior
extremities. Rash occipital
disappear in 1-2 days
without pigmentation or
dequamation.
 Maculopapular Rash
Disease Etiology/ Patogno Prodromal Rash distribution Lymphadenop
Incubation monic athy
period
Rubella Rubellavirus Adenopat No fever in young Rash begins on face, (+)
14-21 days hy (post children, and rapidly spreading to the
auricular nonspecific entire body after fading
and prodromal in older from the face. Rash
occipital) patients. disappearing by fourth
day.

Scarlatina Streptococcus Strawberr Rash occurs after fever

fever hemolyticus y tongue for 12 hours
group A
Exudative
and
membran
ous
tonsilitis
 Papulovesicular Rash
Disease Etiology/ Prodromal Rash distribution
Incubation
period
Varicella Varicella zoster virus Variable fever and Widely scattered red macules and
14-16 days nonspecific systemic papules concentrated on the face
symptoms. and trunk.
Rapidly progressing to clear vesicles
on an erythematous base, pustules,
and then crusts, over 5-6 days.

Variola Variola virus Rash develops after fever Macule, papule, vesicle, and
10-12 days (2-4 days) pustules.
(7-17 days)
 Case No. 1
A-9-month old infant arrives in your clinic because
has developed a rash.
He has had a fever for the past 4 days. He has been
a little cranky when febrile, but resumes his usual
behavior when his temperature is normal.
His temperature measures as high as 40 C each
day, but he has been drinking well and eating
adequately.
He does not have any signs of an upper respiratory
tract infection. The patient has not been immunized
for measles or rubella yet.
You palpate some postauricular lymph nodes.
 What is your differential diagnosis?
 Nonspecific illness for 4 to 5 days without a
rash does not fit measles or rubella, although
he has not been immunized to either
disease.

A hypersensitivity reaction is unlikely,

because he is not on any medication.

Roseola infantum is the most likely diagnosis.

 Roseola Infantum
Roseola infantum is a common benign
infectious disease of infancy (aged 6 - 36
months), caused by HHV-6 or HHV-7.

Characterized by 3-5 days of high fever,

associated with a paucity of physical
findings.

The temperature falls to normal by crisis and

may be accompanied by a morbiliform
rash.
Clinical Findings
The most prominent is the abrupt onset of fever,
often reaching 40.6 C, lasts for 3-4 days. Then the
fever ceases abruptly, and a characteristic rash
may appear.

Rose-pink maculopapules, 2-3 mm in diameter, are

non pruritic, tend to coalesce, and disappear in 1-2
days.

Rash appears on the trunk first, and then spreads to

the neck, upper extremities, face and lower
extremities.
The infant might lethargic and irritable.

Pharynx, tonsils and tympanic membrane may be

injected.

Conjunctivitis and pharyngeal exudate are notably

absent.

Lymphadenopathy, particularly of the occipital,

cervical, and post-auricular is a common finding.
Diagnosis
By clinical manifestations.

No specific serological or virological tests.

Leukopenia and lymphocytopenia are present

early.

Differential diagnosis
Initial high fever may require exclusion of serious
bacterial infection.

All of the diseases with maculopapular eruption.

Complications

Febrile seizures (in 10% patients)

Encephalitis

Prognosis is excellent, confers permanent

immunity

Treatment

Supportive, and fever control should be a

major consideration
 Keep in Mind
A rash following a nonspecific febrile illness
allows you to diagnose roseola and is very
gratifying for you and reassuring to the family.
 Rubella
Rubella is an acute infectious disease characterized
by minimal or absent prodromal symptoms, a 3-day
rash, and generalized lymph node enlargement,
particularly the postauricular, suboccipital and
cervical lymph nodes.

Etiology is rubella virus, presents in the blood and

nasopharyngeal secretions.

Incubation period: 16-18 days (14-21 days)

Clinical Findings
In younger child, first apparent sign of illness is the
appearance of rash.

In adolescent and adult, the eruption is preceded by a

1-5 day prodromal period characterized by low grade
fever, headache, malaise, anorexia, mild conjunctivitis,
coryza, sore throat, cough and lymphadenopathy.

The rash appears first on the face and then spreads

downward rapidly to the neck, arms, trunk and
extremities.

The eruption appears, spreads and disappears more

quickly than rash of measles.

By the end of 1st day, the entire body may be covered

with the discrete pink-red maculopapular rash. On 2nd
day, rash begins to disappear from the face. On 3rd day,
rash has disappeared.
Diagnosis
By clinical manifestations.

Detection of causative agent.

Serology tests: virus neutralizing, CF, HI

Complication
Arthritis

Encephalitis

Purpura
Prognosis is excellent, confers permanent
immunity

Treatment

Symptomatic

Treatment of complications

Preventive measure

Vaccination with MMR.

 Case No. 2
An 18-month-old child developed a fever,
cough, coryza and conjunctivitis 4 days ago.

The rash first appeared on the face 2 days ago.

The child is photophobic and has clear tears

streaming from his eyes.

No history of immunization.
The constellation of symptoms and signs in this
child are highly suggestive of measles.
 Measles
Measles is one of the most contagious
disease of human kind.

It has an attack rate 100%, and in some

areas with a case fatality rate of up to 20%.

It is spread by the airborne route.

Etiology : Genus : Morbilivirus

Family : Paramyxoviridae

Incubation period : 10-11 days

Clinical Findings
Prodromal illness of fever, cough, coryza and
conjunctival inflammation, followed by
appearance of Koplik spots in 2 days.

Koplik spots appear on the buccal mucous

membranes, opposite the molar, and disappear by
the end of 2nd day of the rash.
 Fever : A stepwise increase until the 5th or 6th day
of illness at the height of the eruption

Coryza : Early sneezing; nasal congestion,

mucopurulent discharge

Conjunctivitis : Conjunctival inflammation with

edema of the lids and the caruncles, increased
lacrimation, photophobia

Cough : Caused by inflammatory reaction of the

respiratory tract. Increased in frequency and
intensity, and its climax at the height of the
eruption. Persists much longer, gradually
subsiding over the next several weeks.
A discrete maculopapular rash begins 2 days
later usually when fever peaks, beginning
behind the ears and descending to cover the
whole body, including the palms and soles.

The spots are not very discrete, and become

slightly confluent.

Over few days, rash becomes darker and

desquamates.
Other manifestations
Anorexia, malaise, diarrhea (common in infants)
Generalized lymphadenopathy (in moderate to
severe cases). Enlargement of postauricular,
cervical, and occipital lymph nodes.
Laryngotracheitis, bronchitis, bronchiolitis, and
pneumonitis are present.
 Atypical Measles
Previously immunized with inactivated measles
virus vaccine.

Fever, pneumonitis, pneumonia with pulmonary

consolidation, pleural effusion, and unusual
rash of measles (urticaria, maculopapular,
ptechial, purpuric and vesicular).

Edema of the hands and feet, myalgia, severe

hyperesthesia of the skin.
Severe Hemorrhagic Measles
(Black Measles)
Rare, with sudden onset of hyperpyrexia (40.6 41.1
C).
Convulsion, delirium, or stupor to coma.
Respiratory distress and extensive confluent
hemorrhagic eruption of the skin and mucous
membranes.
Bleeding from the mouth, nose, and bowel may be
severe and uncontrollable.
This type of measles is often fatal, because it
involves DIC.
 Modified Measles
Develops in children who have been passively
immunized with immunoglobulin after exposure
to the disease.
Incubation period is prolonged to 14-20 days.
The illness is milder than ordinary measles.
Fever is low grade, coryza, conjunctivitis, cough
are minimal or absent.
Kopliks spot may negative, and the rash is
sparse and discrete.
Diagnosis
Confirmation of clinical factors.

Isolation of causative agent from blood, urine,

nasopharyngeal secretions during febrile period of
illness.

Serologic tests: HI test, EIA.

Other laboratory: Leucopenia (may fall to 1500/L),

lymphopenia.
Complications
Otitis media
Mastoiditis
Pneumonia
Obstructive laryngitis and laryngotracheitis
Cervical adenitis

Acute encephalomyelitis
Subacute sclerosing panencephalitis
Purpura, anergy, corneal ulceration,
appendicitis, severe diarrhea and
dehydration, kwashiorkor, pyogenic
infection of the skin and septicemia
Prognosis is better in older children.

The majority of deaths resulted from severe

bronchopneumonia or encephalitis.

One attack of measles is generally followed by

permanent immunity.

Treatment

Measles is self-limited disease.

Treatment is chiefly supportive.

Complication Therapy
Hospitalized (Isolated room)

Vitamin A 100.000 IU/orally, once, if malnutrition:

1500 IU/day

Antibiotic:
Ampicillin 100 mg/kgBW/4 divided dose/IV +
Chlorampenicol 75 mg/kgBW/IV/4 for
bronchopneumonia

Cotrimoxazole (TMP 4 mg/kgBW/2 divided

dose) for otitis media

Evaluation of clinical symptoms and give

adequate fluid and diet
Preventive Measures
1. Immunoglobulin

Immunoglobulin will prevent or modify

measles if given within 6 days.

2. Measles virus vaccine

Vaccination prevents the disease in

susceptible exposed individuals if given
within 72 hours.
 Case No. 3
A 6-year-old girl presents with a mild fever and
a few small blisters on her shoulder and chest.
 Varicella
Varicella is a common contagious disease caused
by primary infection with varicella-zoster virus (VZV).

Age distribution is 5-9 years old.

Spread of varicella from a contact is by respiratory

secretion or fomites from vesicles or pustules.

Patient can transmit the disease from 1 day before

the rash appeared, until crusted was dried (5 days
in mild cases, 10 days in severe cases).

Incubation period is 14-16 days (10-21 days).

Primary Varicella
Day 2-4 : Initial viral replication in regional
lymph nodes

Day 4-6 : Primary viremia

Subsequent second round of viral replication in

liver, spleen, and other organs

Secondary viremia seeds capillaries and then

epidermis by day 14-16
Herpes Zoster
VZV spreads from skin/mucosa into sensory
nerve endings
Virus travels to dorsal root ganglion and
becomes latent
Reactivation occurs with decreased cell
mediated immunity
Initial replication occurs in affected dorsal root
ganglion after reactivation
Ganglionitis ensues, with inflammation and
neuronal necrosis
Pain ensues with travel of the virus down the
sensory nerve
Clinical Findings
1 to 3 days of prodrome of low grade fever,
respiratory symptoms, and headache may occur.

The symptoms usually occur simultaneously with the

exanthem.

Crops of red macules that rapidly become small

vesicles with surrounding erythema, form pustules,
become crusted and then scab over.

Rash appears predominantly on the trunk and face,

and more profuse on the proximal parts of the
extremities than on the distal parts.
Distinctive manifestation of the eruption is the
presence of lesions in all stages in any one general
anatomical area: macules, papules, vesicles,
pustules and crusts are located in promixity to each
other.

Characteristic of rash :

A rapid evolution of macule to papule to vesicle

to pustule to crust

A central distribution of lesions that appear in

crops

The presence of lesions in all stages in any one

anatomical area
 Unusual Manifestations
Hemorrhagic
Progressive, and disseminated varicella in
immunocompromised host and a potentially fatal
outcome.

Congenital varicella
This syndrome is extremely rare. Manifestations
include a hypoplastic extremity, zosteriform skin
scarring, microphthalmia, cataracts, choreoretinitis
and abrnomality of the CNS.
Diagnosis

1. Confirmation of clinical factors

a. Development of a pruritic papulovesicular eruption

concentrated on the face and trunk associated with
fever and mild constitutional symptoms

b. The rapid progression of macules to papules, vesicles,

pustules, and crusts

c. The appearance of these lesion in crops, with a

predominant central distribution including the scalp

d. The presence of shallow white ulcers on the mucous

membranes of the mouth

e. The eventual crusting of the skin lesions

2. Detection of the causative agent from vesicular
fluid

3. Serological tests: ELISA, FAMA, RIA, LA

Differential Diagnosis
Impetigo
Insect bites, papular urticaria, and urticaria
Scabies
Dermatitis herpetiformis
Rickettsialpox
Eczema herpeticum and other forms of HSV
infection
Steven Johnson syndrome
Smallpox
Chickenpox Vs. Smallpox
Chickenpox
14-21 days incubation
Mild to no preceding illness
Lesions mostly on trunk
Palms and soles spared
Lesions at varying stages of
development
Scabs form 4-7 days after rash
appears
Vesicles do collaps on
puncture
Smallpox
7-17 days incubation
Fevers, severe systemic
symptomes preceded rash by
2-3 days
Lesions mostly on face, arms,
legs
Palms and soles involved
Lesions at same stage of
development
Scabs form 10-14 days after
rash appears
Vesicles do not collapse on
puncture
Complications (not common)
Secondary bacterial infection
Encephalitis
Varicella pneumonia
Reyes syndrome
Disseminated varicella

Prognosis
Usually a benign disease, clears spontaneously
without sequele.
Infection confers lasting immunity.
Treatment
Self limited disease.

1. Symptomatic:

Paracetamol for high fever

Oral antihistamine and local applications of

calamine lotion may help control the itching

Fingernails should be kept short and clean to

minimize secondary skin infections

Daily bathing
2. Treatment of complications:

- Bacterial infections

- Encephalitis

3. Specific antiviral

Acyclovir 20 mg/kgBW 4 times daily for 5

days (maximum 800 mg).
Preventive Measures
1. Zoster Immunoglobulin

5 mL/IM within 72 hours of exposure to

immunocompromised children

2. Live attenuated varicella vaccine

 Case No. 4
A child arrives at urgent care clinic with fever and
sore throat.

You see about half dozen oropharyngeal lesions

distributed on the soft palate, pharynx and tongue.

A couple of lesions are vesicular with surrounding

erythema. The remaining are shallow ulcers with a
red base.

You also find lesions on the hands and feet.

 What is your diagnosis?

Would you order any diagnostic test?

 If only skin lesions were present, you should
include varicella in the differential diagnosis.

The combination of lesions in the mouth and on

the hands and feed makes hand-foot-and-
mouth disease (HFMD) the most likely diagnosis.
 Hand-foot-and-mouth disease

The enteroviruses most often associated with HFMD

are coxsackievirus A16 and enterovirus 17.

The virus spreads by direct contact with nose and

throat discharges, saliva, fluid from blisters or the
stool of an infected person.

Incubation period: 3-7 days.

Most often in children aged < 10 years old.

Clinical Findings
Mild fever usually precedes the illness by 3-5 days
Headache
Loss of appetite
Sore throat
Non-tender macular or vesicular lesions 4-8 mm
across tongue and buccal mucosa
Rash usually develops 1 day after mouth lesions. The
rash lasts for 1 week and can be tender vesicular,
maculopapular or pustular (4-8 mm) on the hands,
feet and buttock.
Diagnosis
Clinical diagnosis will suffice, and no tests are
required.

Treatment

Symptomatic

Antipiretic

Salt water mouth rinses

Plenty of fluids
Thank You