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 (2- Macule, papule, vesicle, and
10-12 days 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 is afebrile at your
examination.

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.
 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/μL),

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.
 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. 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 Smallpox
14-21 days incubation 7-17 days incubation
Mild to no preceding illness Fevers, severe systemic symptomes
preceded rash by 2-3 days
Lesions mostly on trunk Lesions mostly on face, arms, legs
Palms and soles spared Palms and soles involved
Lesions at varying stages of Lesions at same stage of
development development
Scabs form 4-7 days after rash Scabs form 10-14 days after rash
appears appears
Vesicles do collaps on puncture Vesicles do not collapse on puncture
Complications (not common)
 Secondary bacterial infection
 Encephalitis
 Varicella pneumonia
 Reye’s 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