Clinical Approach to

Fever and Rash

Dr. dr. Ari Prayitno, Sp.A(K)

Departement of Child Health
Faculty of Medicine, Universitas Indonesia, Jakarta
 Outline
Introduction

Etiology

Classification

Clinical pathway of acute exanthema

Exanthema and enanthema diseases

 Introduction
Under certain circumstances a physician who examines a patient with a rash
is charged with a grave responsibility

The causes of fever with rashes very widely, ranging from mild to severe and
even life-threatening if not treated immediately

Error in diagnosis may have a profound → mismanagement :

• Effect on the patient

• Effect on contacts
• Effect on community
 Effect on the Patient

Meningococcemia mistakenly diagnosed as measles

• Specific therapy not given early
• Potentially fatal cases

Scarlet fever was said to have rubella

• Complicating OMA could have been prevented if the correct
diagnosis and appropriate therapy had been instituted
 Effect on the Contacts

Exanthem subitum erroneously label as rubella

• If the mother of the child was 2 month pregnant, it will create
an unnecessary period of anxiety to her who had visions of the
future birth

A child with mild measles was said to have rubella

• A young sibling contact develop severe measles complicated
by pneumonia, that could be prevented by a correct diagnosis
 Effect on the Comunity

HFMD that was labeled to a 6 yrs old boy could lead to a

temporarily closing of the school which maybe a wrong decision

Occasionally a child with stomatitis only maybe erroneously

diagnosed as having the hand-food-and mouth disease.
 Etiology

Infection :
• Bacterial Allergic reaction
• Viruses
• Others

Autoimmune
Malignancies
process
 Infection and Rash

Fever with exanthems → disease that manifested as:

• Fever
• Diffuse skin eruption
• Related with systemic infection
• Commonly caused by virus infection

Mechanism:
• Pathogen invasion
• Multiplication and toxin production
• Immunity host responds
Aspects of Pathogenesis in Exanthems Associated with
Blood-born Dissemination of the Infectious Agent
 Classification
Fever with rashes as symptoms of serious illness and requires
immediate treatment
• Meningococcemia, Kawasaki disease, Dengue hemmorahgic fever, Rocky
mountain spotted fever

Fever with rashes that shows typhical symptoms for certain

infectious disease: mild & often does not need special therapy
• Measles, roseola infantum, eritema infeksiosum, varisela, HFMD

Fever with rashes that appears early in the disease and does not
clearly lead to a particular disease
Diagnosis Establishment
Diagnosis Establishment
 Differential diagnosis
Maculopapular eruptions:

● Measles
● Rubella
● Scarlet fever
● Meningococcemia
● Toxoplasmosis
● Cytomegalovirus infecton
● Roseola infantum
● Enteroviral infection
● Drug eruptions
● Miliaria
● Kawasaki disease
● others
 Differential diagnosis
Papulovesicular eruptions:

• Varicella-zoster infection
• Smallpox
• Excema herpeticum
• Coxsackie virus infection
• Rickettsial pox
• Impetigo
• Insect bites
• Drug eruptions
• Molluscum contagiosum
• Papular urticaria
• others
 Rash characteristics
Measles
• Reddish brown, appears first on the face and neck, progress
downward to involve the trunk and extremities
• Generalized by the 3rd day, and tend to be confluent
• Fades by the 5th or 6th day, followed by desquamation
Rubella
• Pink in color, distributed in the same way as measles, but
generalized within 24 – 48 hrs and fades by the 3rd day
• Usually discrete and does not desquamate
 Rash characteristics

Meningococcemia
• Transient maculopapular eruption precede the petechial,
purpuric rash
• No regular, predictable distribution

Roseola infantum / exathem subitum

• Discrete rose-red papules frequently appear on the chest and
trunk – followed by the face and extremities
• Fades within several hrs and disappear within 2 day
 Rash characteristics
HFMD
• Papulovesicular eruptions in the hand and foot (palmar area), perineal and
enanthemas in the mouth
Kawasaki disease
• Generalized maculopapular rash, palm and soles are swollen and
reddened
Varicella
• Rapid evolution of macules to vesicles and crusts
• Central distributions of lesions, crops
• Presence of all stages of lesions in one area
• Presence of scalp and mucous membrane lesions
 Prodromal period
Measles
• Rash preceded by 3-4 days of fever, conjunctivitis, coryza and cough

Rubella
• Usually no prodromal period in children
• Adolescents may have 1-2 days malaise and low fever
Scarlet fever
• Fever 12 hrs, sore throat and vomiting

Meningococcemia
• Fever, vomiting, irritability, chills, headache in 24 hrs
 Prodromal period
Roseola infantum
• High fever for 3-4 days and irritability
Kawasaki disease
• Non specific fever and sore throat for 2-5 days
Varicella
• Usually absent,
• in adolescent maybe 1-2 days fever, headache, malaise and anorexia
HFMD – hand, foot and mouth disease
• Flu like syndrome for 1-3 days
Onset of fever
Onset of fever
 Exanthema and
enanthema diseases
Measles

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Measles
Rubela
Microsefali

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Rubela
 Ilustrasi Distribusi Ruam Campak dan Rubella
Ruam hari pertama Ruam hari ketiga

Koplik’s spot
pada mukosa
bukkal
Ruam
makulopapular
saling berkonfluensi

Ruam saling terpisah Ruam saling terpisah

satu sama lain satu sama lain
Ruam saling terpisah
(discrete) (discrete)
satu sama lain
(discrete)

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Eksantema Subitum
Demam skarlatina

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Demam skarlatina

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Demam skarlatina
 Circumular pallor
Pipi kemerahan

Ilustrasi Distribusi Demam Ruam terkonsentrasi Strawberry Tongue

pada leher
skarlatina Pastia lines
Ruam terkonsentrasi
pada ketiak

Blanching test (+)

Ruam terkonsentrasi (Schultz-Charlton)
pada daerah genital

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Henoch-Schonlein Purpura
Penyakit Kawasaki
Penyakit Kawasaki

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Penyakit
Kawasaki
Penyakit Kawasaki
Penyakit Kawasaki
Staphylococcal Scalded Skin Syndrome
Dermatitis atopik
 Impetigo
kontagiosa bullosa
Meningococcemia

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Meningococcemia
 Urtikaria
papular pigmentosa
Eritema multiformis
Sindrom Steven – Johnson
Varisela

Putri, N.D. Buku Ilustrasi Demam Ruam. Badan Penerbit IDAI; 2018
Varisela
Variola
Herpes Zoster
Herpes Simplek
Eksema herpetikum
HFMD

*Pasien dengan meningitis aseptik umumnya

**Indikasi: Mioklonus persisten dan berulang, takikardia persisten, gangguan pernapasan, hipoksemi,
prognosis baik, IVIG tidak diindikasikan
kadar saturasi oksigen yang berubah-ubah, perfusi jaringan yang buruk, gangguan kesadaran
HFMD
Molluscum contagiosum
 Miliaria
kristalina rubra
Miliaria
Drug eruptions
Thank You