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NURUL SHAMEEN BT ABDUL RASHID,[object Object],A’QILAH BT BAHARUDIN,[object Object],WAN AHMAD SYAZANI B MOHAMED ,[object Object],FEVER WITH RASH,[object Object]
WHAT IS THAT?,[object Object],FEVER,[object Object],- temporary ↑ in the body’s temperature in response to some disease or illness (37.5°C),[object Object],RASH,[object Object],- temporary eruption of the skin,[object Object],- discrete red spots / generalized reddening,[object Object],- accompanied by itching,[object Object]
In HISTORY TAKING :,[object Object],Exposures,[object Object],	- Ill contacts (home, day care…),[object Object],	- Travelling history,[object Object],	-Pets, insects,[object Object],	- Medications and drugs,[object Object],	- Immunization,[object Object],Features of rash,[object Object],	- Temporal association (onset relative to fever),[object Object],	- Progression and evolution,[object Object],	- Location and distribution,[object Object],	- Pain or pruritus,[object Object]
In PHYSICAL EXAMINATION :,[object Object],Distribution pattern,[object Object],- symmetrical eruption,[object Object],- asymmetrical rashes,[object Object],Morphology,[object Object],- monomorphic,[object Object],- pleomorphic,[object Object],Configuration,[object Object],- linear, annular, grouped, ,[object Object],- Koebner phenomenon (eruption in an area   of local trauma),[object Object]
LINEAR RASH,[object Object]
ANNULAR RASH,[object Object]
KOEBNER PHENOMENON,[object Object]
DIFFERENTIAL DIAGNOSIS OF FEVER WITH RASH,[object Object]
2. fever with rash
2. fever with rash
2. fever with rash
CASE SCENARIO,[object Object],History:,[object Object],9 mo old girl, good general health condition,[object Object],Progressive fever for 5 days (max. 39.50C),[object Object],Coryza, exudative conjunctivitis,[object Object],Severe cough and irritability,[object Object],No diarrhea, no vomiting,[object Object],No recent travel, no pets,[object Object],Rashes	- over trunk, abdomen and back,[object Object],			- appear 4 days after onset of fever,[object Object],		   	- not elevated and no itching,[object Object],			- blanching on pressure,[object Object]
Confluent maculo-papular rash all over the body,[object Object]
MEASLES,[object Object]
EPIDEMIOLOGY,[object Object],Endemic in regions where measles vaccination is not available,[object Object],Young infants - protected by transplacental antibody, but become more susceptible toward the end of the first year.,[object Object],Passive immunity may interfere with effective vaccination until 12 to 15 months of age.,[object Object]
CLINICAL MANIFESTATION,[object Object],Divided into 4 phases :-,[object Object],Incubation,[object Object],- IP = 8 to 12 days from exposure to the onset of symptoms, 14 days from exposure to the onset of rash.,[object Object],Prodromal (catarrhal),[object Object],- cough, coryza, conjunctivitis (Stimson line) Koplik spots (buccal mucosa) ,[object Object]
Exanthematous (rash),[object Object],	- accompanied by high grade fever (40-40.5°C),[object Object],	- The rash starts behind the ears and on the forehead at the hair line spread down to the leg (descending),[object Object],	- show severity of the illness,[object Object],d)	recovery,[object Object]
CONJUNCTIVITIS,[object Object],KOPLIK SPOTS ,[object Object],MACULAR RASH,[object Object]
Other manifestations :,[object Object],Cervical lymphadenitis,[object Object],Spleenomegaly,[object Object],Abdominal pain,[object Object],Mesenteric lymphadenopathy,[object Object],Otitis media,[object Object],Pneumonia		common in infants,[object Object],Diarrhea,[object Object],Liver involvement – common in adult,[object Object]
INVESTIGATIONS,[object Object],Serological test ,[object Object], 	- IgM antibody,[object Object],		- appear in 1-2 days of rash,[object Object],		- persist for 1-2 month,[object Object],[object Object],	- interstitial infiltration,[object Object],	- -vemeasle pneumonia vs bacterial superinfection,[object Object]
DIAGNOSIS,[object Object],Clinical,[object Object],Serology,[object Object],Viral culture,[object Object],PCR,[object Object]
COMPLICATIONS,[object Object],Acute otitis media (10-15%),[object Object],Interstitial pneumonia (50-75% pathological chest XR),[object Object],Myocarditis and pericarditis,[object Object],Encephalitis (1/1000 cases) 7-10 days after rash,[object Object],Subacute sclerosis panencephalitis,[object Object],Mesenteric lymphadenitis,[object Object]
MANAGEMENT,[object Object],TREATMENT,[object Object],Routine supportive care ,[object Object],maintain adequate hydration,[object Object],antipyretics ,[object Object],IV ribavirin  (severe infection),[object Object],High dose for vitamin A supplementation,[object Object]
PREVENTION,[object Object],MMR ,[object Object],Live attenuated measles vaccine,[object Object],1st dose   : 12-15 month of life,[object Object],2nd dose : 4-6 yrs old,[object Object],* Contraindicated for severe immunosupression patient ,[object Object]
RUBELLA,[object Object]
EPIDEMIOLOGY,[object Object],Outbreak of rubella in nonvaccinated groups can occur in adults at their workplaces, prisons, colleges & healthcare centers,[object Object],Transplacental antibody protection only during first 6 month of life,[object Object]
CLINICAL MANIFESTATION,[object Object],IP = 14 to 21 days,[object Object],Rashes - begins on the face, spreads down to the body and lasts far three days.,[object Object],Retroauricular, posterior cervical, posterior occipital lymphadenopathy,[object Object],Erythematous, maculopapular, discrete rashes,[object Object]
Forschheimerspots (rose-colored spots on the soft palate),[object Object],Mild pharyngitis,[object Object],Conjunctivitis,[object Object],Anorexia,[object Object],Headache,[object Object],Low grade fever,[object Object],Polyarthritis,[object Object]
Erythematousmaculopapular  discrete rash,[object Object],Forschheimer spots,[object Object]
INVESTIGATIONS,[object Object],NON-SPECIFIC and do not aid in diagnosis,[object Object],WBC – normal or low,[object Object],Thrombocytopenia – rare,[object Object],Serological test,[object Object],IgM antibody,[object Object],Fourfold rise in specific IgG antibodies in paired acute & convalescent sera,[object Object]
COMPLICATIONS,[object Object],Rarely complicated compared to measles,[object Object],pregnancy – congenital rubella syndrome,[object Object],- IUGR,[object Object],	- cataracts,[object Object],	- deafness,[object Object],	- patent ductusarteriosus (PDA),[object Object]
CONGENITAL RUBELLA SYNDROME,[object Object]
PRINCIPLE OF MANAGEMENT,[object Object],TREATMENT,[object Object],No specific therapy,[object Object],Routine supportive care ,[object Object],Congenital Rubella Syndrome baby should be isolated,[object Object]
PREVENTION,[object Object],Live attenuated MMR vaccine,[object Object],Children at age 12-15 months of life,[object Object],Children at age 4-6 yrs old,[object Object],Pregnant woman should be immunized after delivery,[object Object]
DIFFERENCES BETWEEN MEASLES AND RUBELLA,[object Object]
2. fever with rash
Varicella (chickenpox),[object Object]
Clinical case,[object Object],Vesicular rash on the trunk and face,[object Object],History: 5 y old boy, no special past medical history,[object Object],Low grade fever (38.30C) for 48 h,[object Object],Attends school,[object Object],No travel history,[object Object],No pets,[object Object]
Varicella (chickenpox),[object Object],Causes: Varicella zoster virus (VZV, herpesvirus family),[object Object],Human are the only natural host,[object Object],Chickenpox (vericella) = manifestation of primary infection,[object Object],Highly contagious among susceptible individuals; secondary attack rate is more than 90%),[object Object],Contagiosity: 2 days before to 7 days after the onset of the rash, when all lesions are crusted,[object Object]
Peak age: 5 to 10 years old,[object Object],Peak seasonal infection: late winter and spring,[object Object],Transmission: direct contact, droplet, and air,[object Object],Incubation period: 14-16 days,[object Object]
Clinical manifestation,[object Object],Prodromal symptoms: fever, malaise, anorexia (preceed the rash by 1 day),[object Object],Characteristic rash: small red papules> Erythematous papules> vesicular> vesicles ulcerate, crust and heal (new crops appear for 3-4 days),[object Object],Pattern of rash: beginning on the trunk followed by the head, face, and less commonly the extremities,[object Object],Pruritusis universal and marked,[object Object],Lesions may also present on mucosa membranes,[object Object],Lymphadenopathy may be generalized ,[object Object]
2. fever with rash
Complication,[object Object],Common,[object Object],More severe for neonates, adults, and immunocompromised persons.,[object Object],-	Secondary infection of skin by streptococci pr staphylococci,[object Object],[object Object]
Pneumonia (15-20% 0f healty adults and immunlcompromised persons, uncommon in healthy children)
Myocarditis, pericarditis, orchitis, hepatitis, ulcerative gastritis, glomerulonephritis and athritis may complicate
Reye syndrome may follow varicella (aspirin use is contraindicated)
Neurological complication: post infectious enencephaly, cerebellar ataxia, nystagmus and tremor. ,[object Object]
Treatment,[object Object],Symptomatic therapy: Nonaspirin antipyretics, cool baths, careful hygiene,[object Object],Antiviral treatment: acyclovir, famciclovir, valacyclovir,[object Object]
2. fever with rash
Prevention,[object Object],Children with chickenpox should not return to school until all vesicle have crusted,[object Object],Live attenuated varicella (primary prevention),[object Object],Passive immunity by VZIG (secondary prevention),[object Object]
Must be administered by 96h after exposure (or better if < 72h),[object Object]
Hand,foot and mouth disease,[object Object]
Hand,foot and mouth disease,[object Object],most often occurs in children under 10 years old. ,[object Object],Causes: coxsackievirus A16, enterovirus 71 (EV71) and other enteroviruses. ,[object Object],The enterovirus group includes polioviruses, coxsackieviruses, echoviruses and other enteroviruses. ,[object Object], more frequent in summer and early autumn (in temperate countries) ,[object Object]
moderately contagious. ,[object Object],A person is most contagious during the first week of the illness.,[object Object],transmitted from person to person via direct contact with nose and throat discharges, saliva, fluid from blisters, or the stool of infected persons.,[object Object],(incubation period) is 3 to 7 days. Fever is often the first symptom of HFMD followed by blister/rash.,[object Object]
Clinical manifestation,[object Object],mild fever, ,[object Object],poor appetite, ,[object Object],malaise ("feeling sick"), and ,[object Object],frequently a sore throat. ,[object Object],One or 2 days after the fever begins, painful sores develop in the mouth. They begin as small red spots that blister and then often become ulcers. ,[object Object],They are usually located on the tongue, gums, and inside of the cheeks. ,[object Object],The skin rash develops over 1 to 2 days with flat or raised red spots, some with blisters on the palms of the hand and the soles of the feet. ,[object Object]
Blister on the palms of the hands ,[object Object],Blister on the soles of the feet ,[object Object],Blister then become ulcer on the inner gums ,[object Object],Blister on the dorsum of the feet ,[object Object]
Complication,[object Object], HFMD caused by coxsackie virus A16 infection is a mild disease and nearly all patients recover within 7 to 10 days. ,[object Object],Complications are uncommon. ,[object Object],HFMD caused by Enterovirus EV71 may be associated with neurological complications such as aseptic meningitis and encephalitis ,[object Object]
Treatment,[object Object],no specific effective antiviral drugs and vaccine available for the treatment of HFMD. ,[object Object],Symptomatic treatment is given to provide relief from fever, aches, or pain from the mouth ulcers.,[object Object],Dehydrationis a concern because the mouth sores may make it difficult and painful for children to eat and drink. ,[object Object]
Prevention,[object Object],good hygienic practices. Preventive measures include: ,[object Object],a. Frequent hand washing, especially after diaper changes, after using toilet and before preparing food, ,[object Object],b. Maintain cleanliness of house, child care center, kindergartens or schools and its surrounding, ,[object Object],c. Cleaning of contaminated surfaces and soiled items with soap and water, and then disinfecting them with diluted solution of chlorine-containing bleach (10% concentration), ,[object Object],d. Parents are advised not to bring young children to crowded public places such as shopping centers, cinemas, swimming pools, markets or bus stations, ,[object Object],e. Bring children to the nearest clinic if they show signs and symptoms. Refrain from sending them to child care centers, kindergartens or schools. ,[object Object],f. Avoidance of close contact (kissing, hugging, sharing utensils, etc.) with children having HFMD illness to reduce of the risk of infection ,[object Object]
MENINGOCOCCAL DISEASE,[object Object]
[object Object]
 transmission: person-to-person by respiratory dropletscolonization of URT  penetrate into bloodstream  go to CNS and causing meningitis (meningococcal meningitis) / infect the blood vessel (meningococcemia),[object Object],[object Object]
cutaneous signs:Maculopapular – early, often on a painful joint or pressure point,[object Object],Petechiae (50-70%) – distribute at trunk and extremities (can be anywhere else),[object Object],Purpura (may start anywhere on the body and then spread) and necrotic area,[object Object],[object Object],. ,[object Object]
Meningococcal septicemia can kill children in hours, therefore optimal outcome requires immediate recognition, prompt resuscitation and antibiotics.,[object Object],Although there are now polysaccharide conjugate vaccines against groups A and C meningococcus, there is still no effective vaccines for group B meningococcus,[object Object]
CLINICAL CASE,[object Object],History: 7 y. old boy, good general health condition,[object Object],Sudden onset of sore throat since 24hrs and,[object Object],fever at 39oC. Abdominal pain and,[object Object],1 episode of vomiting,[object Object],No conjuntivitis,,[object Object],No rhinitis,,[object Object],No hoarseness,[object Object],No cough,[object Object],Attends primary school, no recent travel,[object Object]
Scarlet Fever,[object Object],[object Object]
 transmission: direct contact through droplets
 symptoms:
 rashes:
 develop 24 hours after the fever
 can begins at  below  ears , neck, chest and stomach then spread all over the body within 1 to 2 days
 look like sunburn and feel like sandpaper
 more apparent at skin fold of elbow, armpit and groin area
 last for about 2-7 days

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