1. Fever with Rash
Fever With Rash
Chooi Yuo Hao (Eugene)
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2. •Varicella Zoster Virus (VZV)
• Perinatally acquired varicella
•Kawasaki Disease
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3. History Taking
• Introduction
• Chief complaints
• HOPI
• Past history (Medical and Surgical)
• Birth history
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• Feeding history
• Developmental history
• Immunization history
• Drug history
• Family history 3
• Social and environmental history

4. Physical examination
• General examination
• Systemic examination
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5. Varicella Zoster Virus (VZV)
• 1 of the known human herpes viruses
• Varicella Zoster Virus (VZV) – Chicken Pox
• Herpes Zoster – Shingles
• Neurotropic human herpes virus with similarities to
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herpes simplex virus
• Air-borne and highly contagious disease
• Causes primary, latent and recurrent infections
• Increased morbidity and mortality in
adolescent, adults, and immunocompromised
persons 5
• Predisposed to severe group A streptococcus and
Staphylococcus aureus infection

6. Clinical Manifestation
• Prodromal symptoms
• Nausea, loss of appetite, aching muscle and headache
• Fever (mostly low grade), malaise, 24-48hrs later
associated with vesicular rash (successive crops of
pruritic vesicles that evolve to pustules, crusts and
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at times scar4)
• Rashes starts from the scalp, face or trunk, upper
extremities and lower extremities
• Some children might not have prodromal
symptoms, they begins with vesicular rash and fever
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7. Fever With Rash
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Varicella lesion

8. Fever With Rash
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Vesicular rash of chicken pox

9. Fever With Rash
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Haemorrhagic chickenpox

10. Complications
• Bacterial superinfection
• Staphylococcal
• Streptococcal
• May lead to toxic shock syndrome or necrotizing fasciitis
• Central nervous system
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• Generalized encephalitis
• Aseptic meningitis
• Immunocompromised
• Haemorrhagic lesions
• Pneumonitis
• Progressive and disseminated infection 10
• Disseminated intravascular coagulation

11. Treatment
• Antiviral treatment – Acyclovir
• Human varicella zoster immunoglobulin (ZIG) is
recommended for high-risk immunosuppressed
individuals
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12. Prognosis
• Quite good excluded immunosuppressed patients
• Resolves spontaneously – self limited
• Mortality rate 2-3 per 100,000 cases
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13. Prevention
• Difficult to prevent as the infection is highly
contagious for 24-48 hour before the rash appears.
• Live attenuated VZV vaccine can be administer
• Postexposure prophylaxis – VZV vaccine or oral
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acyclovir
Beware of admitting a chickenpox
contact to a clinical area with
immunocompromised children 13

14. Perinatally Acquired Varicella
• Maternal infection (onset of rash) within 5 days
before and 2 days after delivery
• Mortality rate is high, due to severe pulmonary
disease or widespread necrotic lesions of viscera
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• The production and transplacental passage of
maternal antibodies that modify the course of illness
in new-borns
• Exposed susceptible women can be protected with
varicella zoster immune globulin (VZIG) and treated
with acyclovir.
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15. • Women with varicella lesions should be isolated
from their newborns, breast feeding is
contraindicated; when all the lesions have crusted,
breast feeding should be commence
• Neonates with varicella lesions should be isolated
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from other infants but not from their mothers.
• Infants born in the high-risk period should also
receive zoster immune globulin and are often also
given acyclovir prophylactically
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16. Summary
• Primary, latent and recurrent infections
• Primary infection is manifested as varicella – chickenpox
• Results in establishment of a lifelong latent infection of
sensory ganglion neurons
• Reactivation of the latent infection causes herpes zoster –
shingles
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• Increase morbidity and mortality in adolescents, adults and
immunocompromised persons, and predisposes to severe
group A streptococcus and Staphylococcus aureus infections
• Can be treated with antiviral drugs
• Initial infection can be prevented by immunization with live-
attenuated VZV vaccine
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17. Kawasaki Disease
• Also known as acute febrile mucocutaneous
syndrome
• A systemic febrile condition affecting children
usually <5 years old
• Aetiology remains unknown, possible bacterial
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toxins or viral agents with genetic predisposition
• Aneurysms of the coronary arteries are an
important complication
• Affects children 6 months – 4 years old, with a peak
at the end of the first year
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18. Diagnostic criteria
• Exclusive diagnosis
• Fever (HGF, remittent and unresponsive to antibitics)
lasting at least 5 days
• At least 4 out of 5 of the following
• Bilateral non-purulent conjunctivitis
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• Mucosal changes of the oropharynx (injected pharynx, red
lips, dry fissured lips, strawberry tongue)
• Change in extremities (oedema and/or erythema of the
hands or feet desquamation, beginning periungually)
• Rash (usually truncal), polymorphous but not vesicular
• Cervical lymphadenopathy 18
• Illness not explained by other disease process

19. Fever With Rash
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Red, cracked lips and conjunctiva inflammation

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Congestion of bulbar conjunctiva 20

21. Fever With Rash
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Strawberry tongue

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Peeling of fingers

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Desquamation of the fingers 23

24. Fever With Rash
Indurative edema 24

25. Other helpful signs
• Indurated BCG scar
• Perianal excoriation, irritability
• Altered mental state
• Aseptic meningitis
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• Transient arthritis
• Diarrhoea, vomiting, abdominal pain
• Hepatoslenomegaly
• Hydrops of gallbladder
• Sterile pyuria
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26. Investigation
• Full blood count
• Anaemia, leukocytosis, thrombocytosis
• ESR and CRP elevated
• Serum albumin <3gdl; Raised alanine
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aminotrasaminase (ALT)
• Urine > 10 wbc/hpf
• Chest x-ray, ECG
• Echocardiogram in the acute phase and repeat at
6-8 weeks or earlier if indicated
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27. Fever With Rash
Coronary angiogram demonstrating giant aneurysms of the
LAD with obstruction and giant aneurysms of the RCA with 27
area of severe narrowing

28. Complication
• Coronary vasculitis, usually within 2 weeks of
illness
• Asymptomatic
• Myocardial infection
•
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Myocardial infarction
• Pericarditis
• Myocarditis
• Endocarditis
• Heart failure
• Arrhythmias
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29. • Incomplete Kawasaki Disease (kindly refer to the 2nd
edition of paeds protocol pg 115)
• Atypical Kawasaki Disease (kindly refer to the 2nd
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edition of paeds protocol pg 115)
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30. Fever With Rash
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Evaluation of Suspected Incomplete Kawasaki Disease

31. Treatment
• Primary treatment
• IV Immunoglobulins 2 Gm/kg infusion over 10-12
hours
Therapy <10 days of onset effective in preventing
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coronary vascular damage
• Oral Aspirin 30 mg/kg/day for 2 weeks or until
patient is afebrile for 2-3 days
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32. Maintenance
• Oral Aspirin 3-5 mg/kg daily (anti-platelet dose) for
6-8 weeks or until ESR and platelet count normal
If coronary aneurysm present, then continue aspirin
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until resolves
Alternative: Oral Dipyridamole 3-5mg/kg daily
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33. Prognosis
• Complete recovery in children without coronary
artery involvement
• Most (80%) 3-5mm aneurysm resolve
• 30% of 5-8mm aneurysm resolve
• Prognosis worst for aneurysms > 8mm; mortality
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1~2%
• Good prognosis for aneurysms <4mm
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34. Summary
• Mainly affects infants and young children
• The diagnosis is made on clinical features such as
• Fever lasting at least 5 days
• At least 4 out of 5 of the following
• Bilateral non-purulent conjunctivitis
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• Mucosal changes of the oropharynx (injected pharynx, red lips, dry
fissured lips, strawberry tongue)
• Change in extremities (oedema and/or erythema of the hands or feet
desquamation, beginning periungually)
• Rash (usually truncal), polymorphous but not vesicular
• Cervical lymphadenopathy
• Complications – Coronary artery aneurysms and
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sudden death
• Treatment – Intravenous immunoglobulin and aspirin

35. References
• Hussein Imam, Ng H.P., Thomas T. (2008). Paediatrics
Protocols for Malaysian Hospitals (2nd edition): pg 6,78,115-
116
• Lissauer T., Clayden G. (2007). Illustrated textbook of
Paediatrics (3rd edition): pg 230-232, 237-238
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• Kliegman R.M., Beherman R.E., Jenson H.B., Stanton B.F.
(2007). Nelson textbook of Paediatrics (18th edition)
• Klaus W., Richard A.J. (2009). Fitzpatrick’s Color Atlas &
Synopsis of Clinical Dermatology (6th edition): pg 833
• Kliegman R.M., Marcdante K.J., Beherman R.E., Jenson H.B.
(2007). Nelson Essentials of Paediatrics (5th edition): pg 470-
472
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36. Fever With Rash
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