FEVER AND

RASH
Dr. Nazdar Alkhateeb
 Definitions
• What is an exanthem?
• Greek origin “exanthema” which means “a breaking
out”
• Widespread erythematous rash which is usually
associated with systemic symptoms such as
fever, malaise, myalgia, and headache.
• They are commonly caused by infectious
agents particularly viruses and occasionally
bacteria.
• A rash that appears abruptly and affects
several areas of the skin simultaneously.
• Commonly described as “morbilliform” which means
“erythematous macules and papules that resemble a
measles rash.”
• Enanthem: An eruption upon a mucous membrane
(note: When there is a rash, examine the mucous
membranes as well)
• Viral exanthems are more common in children.
• Drug eruptions are more common in adults.
If you are unsure of the correct dermatological term for a lesion,
you should carefully describe it:
1. Raised or flat.
2. Crusty (note: e.g., chickenpox) or scaly (note: e.g., psoriasis)
3. Color.
4. blanching on pressure
1. note: fading when the lesion is pressed, for 5 seconds.
Maculopapular rash resulting from increased vascularity
blanch as the vessels empty on pressure [?? Dr. Nazdar],
while hemorrhagic lesions such as petechiae don’t blanch.
5. Size of the lesion.
6. Distribution (note: examine other sites of the body to
determine the distribution)
 Approach to fever and rash
Must ask:
1. When did it first start?
• Note: + onset – acute or chronic
2. Is the child ill? (note: The child is usually relatively healthy, and in only a
few of these diseases are they significantly “ill”, e.g., meningococcal
meningitis)
3. Is the rash itchy?
4. Past medical history.
5. Immunization history (Note: Some etiologies of fever and rash are vaccine-
preventable)
6. Contact with anyone ill in family or school.
7. Evolution of rash.
8. Associated symptoms. (note: + Did they start with, before, or after the rash)
9. Season (note: Some diseases are more common in certain seasons)
10. Drug history.
 Must Check
Describe the rash, concentrate on the following:
1. Characteristic of rash:
• macular or papular
• vesicular or purpuric
2. Examine for blanching.
3. Distribution (note: examine the whole body): measles and
rubella from face to the trunk (note: cephalocaudal spread)
while roseola and chickenpox from trunk to limbs (note:
centrifugal spread) .
4. Presence of enanthem (note: examine the mucous
membranes)
5. General examination (note: General status, lymph nodes,
organomegaly, etc.)
 Investigations
• In general, investigations are rarely required
(note: Diagnosis is usually clinical)
• Blood sample for culture and meningococcal PCR
are required in meningococcemia (note: indicated
in children that are ill)
• Culture may prove negative as most children
receive IM penicillin prior to admission to the
hospital.
• If the rash is petechial a platelet count is
required.
1. ROSEOLA
INFANTUM
 Roseola Infantum
• Caused by double-stranded DNA human herpes virus (HHV) type 6
and 7.
• The peak incidence is between 6 months and 1 years of age (note: it
can occur between 6 months and 2 years however) [because
transplacental antibodies drop]
• Transmission is by respiratory secretion of an asymptomatic family
member (note: + saliva)
• Note: incubation period is 5-15 days
• Treatment: Acetaminophen and ibuprofen for fever. No other treatment
is required (viral disease) (note: usually self limited)
• About 10-15% of children will develop febrile seizures.
• Watch this video for more information
 Clinical features
• Onset is sudden with spiking fever as high as 41C (no physical
finding to explain fever). The fever lasts 3-5 days.
• Note: diarrhea, cough, and droopy or swollen eyelids.
• The rash appears on 4th day with a drop of temperature (note:
The characteristic feature [Dr. Nazdar] is that the rash occurs
after the fever has settled down)
• Start on the trunk and spread rapidly to the arm and neck
(macular and maculopapular).
• It is nonpruritic and blanches on pressure. The rash
lasting 1-2 days.
• A febrile seizure is principal complication, they may be the
first sign of illness and may occur with the sudden rise of
temperature.
• Roseola infantum is responsible for up to 1/3 of febrile
convulsions in the 1st year of life.
 Investigations
• Routine laboratory findings are non-specific.
• CBC shows progressive leukopenia (3000-5000)???
• Encephalitis with roseola is characterized by:
• Pleocytosis (30-200 cells/mm3) with mononuclear cell
predominance
• Elevated protein concentration
• Normal glucose concentration
• Serological testing showing a fourfold rise in acute
and convalescent sera or documentation of HHV-6
DNA by PCR in the cerebrospinal fluid is
diagnostic.
• PCR has also been used to detect HHV-6 in blood but
may not be sensitive in primary infection.
• Many children have a febrile illness without a
rash, and many have a subclinical infection.
• It can be misdiagnosed as measles or rubella.
• Infants in the febrile stage may be prescribed
antibiotics, and then, when the rash develops, it’s
erroneously attributed to an allergic reaction to the
drug
• Rare Complications include:
1. Aseptic meningitis
2. Encephalitis
3. Hepatitis
4. Mononucleosis-like syndrome
5. Virus-associated hemophagocytic syndrome
2. MEASLES
 Measles

• Note: Notifiable disease

• Also known as rubeola or 10-day measles.
• Caused by Measles morbillivirus.
• It is caused by a single-stranded lipid enveloped
RNA virus.
• Although its incidence has been reduced by the
production of vaccines in 1963, the incidence is
now rising as the MMR uptake is poor.
• Video
 Pathophysiology
• The measles virus infects the upper respiratory tract
and regional lymph nodes and is spread
systemically during a brief, low-titer primary
viremia.
• A secondary viremia occurs within 5-7 days as
virus- infected monocytes spread the virus to the
respiratory tract, skin, and other organs.
• The virus is present in respiratory secretions, blood,
and the urine of infected individuals.
 Transmissio
•
n
It is transmitted by droplets or via the airborne route
and is extremely contagious.
• Infected persons are contagious from 1-2 days before
onset of symptoms—from about 5 days before to 4
days after the appearance of rash. [4 days before to 4
days after onset of rash according to CDC and WHO]
• Immunocompromised persons can have prolonged
excretion of contagious virus.
 Clinical Manifestations
• Measles infection is divided into four phases:
1. Incubation: is 8-12 days from exposure to symptom onset
and a mean of 14 days (range: 7-21) from exposure to rash
onset.
2. Prodromal (catarrhal): a 3-day period characterized by cough,
coryza, and conjunctivitis (note: non-purulent papillary
conjunctivitis) (with photophobia)—3 Cs—and the
pathognomonic enanthem Kolpik spots—gray-white, sand-
grain-sized dots on the buccal mucosa opposite the lower molars—
that last for 12 to 24 hours. Kolpik spots are present in 70% of
cases (note: Koplik spots usually precede the measles rash and may
be seen for the first day or two after the rash appears [1])
• The conjunctiva may reveal a characteristic transverse line
of inflammation along the eyelid margin (Stimson line).
 • The 3 Cs occur during the secondary viremia of the
exanthematous phase, which often is accompanied by high
fever (40-40.5°C).
3. Exanthematous (rash): the macular rash begins on the head
(often above the hairline, and the back and anterior of the
ears) and spreads over most of the body in a cephalad to
caudal pattern over 24 hours (note: The rash does not
migrate; when it spreads downwards, it also stays in the
face [? Dr. Nazdar]). Areas of the rash are often confluent.
The rash fades in the same pattern, and illness severity is
related to the extent of the rash. As the rash fades, it
undergoes brownish discoloration and desquamation.
• The rash may be petechial or hemorrhagic (black measles).
• Cervical lymphadenitis, splenomegaly, and mesenteric
lymphadenopathy with abdominal pain may be noted with the
rash.
4. Recovery.
Koplik Spots
 Investigations
• Routine laboratory findings are non-specific and do
not aid in diagnosis.
• Leukopenia is characteristic.
• In encephalitis CSF shows:
• Increased protein
• Lymphocytic pleocytosis
• Normal glucose levels
• Serological testing for IgM antibodies that appear
within 1-2 days of the rash and persist for 1-2 months in
unimmunized persons confirms the clinical diagnosis,
though IgM antibodies may be present only
transiently in immunized people.
• PCR
 Treatmen
• t light because of the conjunctivitis)
Supportive (avoid bright
• Children who are admitted to the hospital should be isolated.
• Vitamin A 100,000 IU for children aged 6 months to 1 year. 200,000 IU
for children older than 1 year.
• In immunocompromised, ribavirin may be needed.
• Note – management of unvaccinated contacts: the MMR vaccine, if given
within 72 hours of measles exposure, will provide protection in some
cases, and giving the vaccine within 72 hours is recommended for all
unvaccinated contacts. You can also give immunoglobulin (IG) within six
days of exposure. Do not administer MMR vaccine and IG simultaneously,
as this practice invalidates the vaccine.
 Complications
• Otitis media, pneumonia, and diarrhea are
more common in infants.
• Liver involvement is more common in adults.
• Otitis media is the most common complication of
measles infection (note: pneumonia is the most
common cause of death in young children)
• Interstitial (measles) pneumonia can occur, or
pneumonia may result from secondary bacterial
infection with Streptococcus pneumoniae,
Staphylococcus aureus, or group A streptococcus.
Persons with impaired cell-mediated immunity may
develop giant cell (Hecht) pneumonia, which is
usually fatal.
• Myocarditis and mesenteric lymphadenitis are
infrequent complications.
• Encephalomyelitis occurs in 1-2 per 1,000 (or 1 in
5000???) cases and usually occurs 2-5 days after the
onset of the rash. Early encephalitis probably is caused
by direct viral infection of brain tissue, whereas later
onset encephalitis is a demyelinating, and probably
an immunopathological, phenomenon.
• Subacute sclerosing panencephalitis (SSPE) is a late
neurological complication of slow measles infection
that is characterized by progressive behavioral and
intellectual deterioration and eventual death. It
occurs in approximately 1 in every 1 million cases of
measles, an average of 8-10 years after measles.
There is no effective treatment.
 Prognosi
• s result from
Deaths most frequently
bronchopneumonia or encephalitis, with much
higher risk in:
• Persons with malignancy,
• Severe malnutrition
• Age under 5 years
• Immunocompromise (such as HIV infection)
• Late deaths in adolescents and adults usually
result from SSPE.
• Other forms of measles encephalitis in
immunocompetent persons are associated with a
mortality rate of approximately 15%, with 20-30% of
survivors having serious neurological sequelae.
 Modified Measles
• The term modified measles describes mild cases of
measles occurring in persons with partial protection
against measles.
• Modified measles occurs in:
1. Persons vaccinated before 12 months of age or with
co-administration of immune serum globulin
2. In infants with disease modified by transplacentally
acquired antibody
3. In persons receiving immunoglobulin
3. RUBELLA
 Rubella
• Also known as German measles or 3-day measles.
• Caused by rubella virus, a single-stranded RNA
virus.
• Transmission is by droplet inhalation and
transplacental.
• It is generally a mild disease in childhood, but it
can cause severe damage to the fetus.
• Incubation period is 14-21 days.
• Is most contagious from 2 days before to 5-7 days
after the onset of rash. (7 days before to 7 days after
for CDC and WHO, I will kill myself - Bashar)
 Clinical Manifestations
• Mild prodromal period may occur but often absent in
children.
• It’s characterized by malaise, anorexia, low-grade fever or
no fever at all, and palatal petechiae known as Forchheimer
spots, that precede or accompany the rash, are present in
20% of cases.
• Note: however, similar lesions may also be seen in
measles and scarlet fever, so the presence of Forschheimer
spots is not pathognomonic for rubella.
• The characteristic signs of rubella are tender retroauricular,
posterior cervical, and posterior occipital
lymphadenopathy that starts 24 hours before the
erythematous, maculopapular, discrete rash appears and
lasts for 1 week.
• The rash begins on the face and spreads to the body,
lasting for 3 days, and is less prominent than that of
measles. The rash characteristically leaves the face
while reaching the trunk (note: Unlike measles, where
it stays on the face)
• Other manifestations of rubella include
mild pharyngitis, conjunctivitis, and
headache.
 Congenital Rubella
• This syndrome usually involves the infant whose
mother has rubella in first trimester of
pregnancy.
• Note: Risk depends on gestational age
• <10 weeks: 90% risk of some severe damage
(deafness, cataract, and congenital heart disease
(PDA))
• 13-16 weeks: 30% risk of hearing impairment
• >16 weeks: the risk to the fetus is minimal.

• Watch this video

Cataract in Congenital
Rubella
 Investigations
• Routine laboratory findings are non-specific
and generally do not aid in diagnosis.
• The white blood cell count usually is normal or
low.
• Thrombocytopenia rarely occurs.
• Diagnosis is confirmed by serological testing for IgM
antibodies (typically positive 5 days afer symptom
onset) or by a fourfold or greater increase in specific
IgG antibodies in paired acute and convalescent sera.
• CRS cases can have detectable IgM until 3 months of
age and stable or rising IgG titers over the first 7-11
months of age.
 Treatmen
1. Supportive.
t
2. Isolation is required for 7 days.
3. Congenital rubella may be contagious for over 1
year.
 Complications
1. Encephalitis
2. Thrombocytopenia
3. Arthritis, most commonly in the fingers, wrists, and
knees.
4. SCARLET
FEVER
 Scarlet Fever
• Note: notifiable disease
• It’s a disease caused by infection with group A
beta hemolytic streptococci which produce
erythrogenic exotoxin that produce a characteristic
rash.
• The initial focus is usually a sore throat or might
be a
skin infection.
• Incidence: common in 4–8-year-olds (note: school
age children
• Incubation period: 2-4 days
 A scarlet woman lying naked on a sandy beach for 2–4 days, got
a sunburn on all her body that lasted for 5 days and has a school age child

Clinical Manifestation
• Characterized by a sudden onset of fever, rigor, headache, vomiting and sore
throat.
• When examining the mouth, there is white strawberry tongue
followed within days by red strawberry tongue.
• When examining the throat, we notice follicular pus (follicular
tonsillitis).
• The face of child will be flushed, characteristically there’s
circumoral pallor, that is to say; the area around the mouth is spared from
redness.
• The rash feels like sandpaper (rough), might be itchy, and
blanches on pressure. Starts on the trunk then spreads to the
neck, groin and axilla within 24 hours.
• The rash is concentrated in the skin folds and has a name (Pastia’s
lines), followed by desquamation within few days, and is prominent on the
fingertips, axilla and groin (Note: sloughing/peeling of the fingertips occurs
during convalescence)
 Note: DDX of peeling fingertips[1]
• Contact dermatitis
• Kawasaki’s disease
• Scarlet fever
• Psoriasis
• Dyshidrosis
• Hypervitaminosis A
• Graft vs Host disease
• Liver transplant
• Blistering distal dactylitis
• Bullous impetigo
• Epidermolysis bullosa
• Burns
• Keratolysis exfoliative
• Etc.
White strawberry tongue
Red strawberry tongue
Circumoral Pallor
 Clinical features

• White and red strawberry tongue

Circum oral pallor Exfoliation
Diagnosis, Treatment, and Sequelae
• Clinical.
• Throat swab for culture.
• Detection of ASO titer and anti-DNAase B in the serum.
• Treatment
• 10 days orally administered penicillin or erythromycin
eradicates the organism.
• Note: keep them away from nursery or school for at least 24
hours after starting treatment with antibiotics.
• Sequelae:
1. Rheumatic fever (note: Rheumatic fever can develop about 20 days after an
individual has the untreated or poorly treated strep throat or scarlet fever)
2. Acute glomerulonephritis (note: after 10 days)
3. Note: + otitis media
5. ERYTHEMA
INFECTIOSUM
 Erythema infectiosum (Slapped
cheek syndrome)
• It is a mild self-limited disease.
• Slapped cheek syndrome (fifth disease) is common in children and should
clear up on its own. It's rarer in adults but can be more serious.
• The first sign is usually feeling unwell for a few days.
• Incubation period: 4-14 days, rarely, may last 21 days.
• Note: spread primarily via aerosolized respiratory droplets. Transmission also
occurs through blood products and from mother to fetus.
• Note: The infectivity period lasts from seven days prior to appearance of a rash
up to the date of appearance of the rash
• Symptoms may include:
• a high temperature of 38C or more
• a runny nose and sore throat
• a headache
• Watch this video
 How long it lasts
• The cheek rash normally fades within 2 weeks.
• The body rash also fades within 2 weeks, but
sometimes comes and goes for up to a month,
especially if the patient is exercising, hot, anxious
or stressed.
• Adults might also have joint pain and stiffness. This
can continue for many weeks, even after the other
symptoms have gone.
 Treatmen
• Rest
t
• Continue normal feeding.
• Paracetamol or ibuprofen for a high temperature,
headaches or joint pain.
• Moisturizer on itchy skin.
• Antihistamine for itching.
Characteristics of rash
• The rash progresses through 3
stages:
1. Erythema in cheek (slapped
cheek rash), with circumoral
pallor.
2. Rash with central clearing
(reticular appearance): An
erythematous symmetric,
macupapular, truncal rash appears
1-4 days later, then fades as
central clearing giving a distinctive
lacy reticular appearance.
3. Periodic recurrence of rash with
exercise and environmental
temperature change over 1-3 wks.
Lacy, reticulated rash
 Investigations
• Hematological abnormalities occur with parvovirus
infection including reticulocytopenia lasting 7-10
days, mild anemia, thrombocytopenia, leukopenia,
and neutropenia.
• PCR of blood and CSF.
• Serological tests showing specific IgM Ab to
parvovirus are diagnostic, demonstrating an
infection that probably occurred in the prior 2-4
months.
 Treatmen
•
t
Routine supportive treatment.
• Transfusion may be required for aplastic crisis.
• Intrauterine transfusion in cases of hydrops fetalis.
• IVIg for immunocompromised persons with severe
anemia or chronic infection.
• Note: Once the patients gets the rash, they are
probably not contagious. So, it is usually safe for
the child to return to school or a child care center.
 Complications

• Parvovirus B19 infects the erythroblastic red cell

precursors in the bone marrow and can lead to aplastic
crisis in children with chronic hemolytic anemia
(sickle cell and thalassemia) and in immunodeficient
children e.g. malignancy, who are unable to
produce antibody response to neutralize the
infection.
• There's a very small risk of miscarriage or
other complications in pregnancy.
• Fetal disease: hydrops fetalis and death due to severe
anemia.
6. CHICKENPOX
AND SHINGLES
• Chickenpox and zoster are caused by varicella-zoster virus (VZV, HH3), an
enveloped, icosahedral, double-stranded DNA virus that is a member of the
herpesvirus family.
• Chickenpox (varicella) is the manifestation of primary infection.
• Zoster (shingles) is the manifestation of reactivated latent infection of
endogenous VZV.
• Transmission is by droplet, direct contact, and contact with soiled
material.
• Note: direct contact with the fluid from a shingles rash can also
spread VZV.
• Incubation period: 14 days. [14-16 (range: 10-21) for CDC, WHO, AND
Nelson, finally]
• Infectivity is from 2 days before (most infectious) the eruption till all the
lesions are encrusted.
• Note: the child should be isolated and not go to school
• Watch this
 Pathogenesis
• VZV infects susceptible individuals via the conjunctivae or
respiratory tract → replicates in the nasopharynx and
upper respiratory tract → It disseminates by a primary
viremia → infects regional lymph nodes, the liver, the
spleen, and other organs → A secondary viremia follows,
resulting in a cutaneous infection with the typical
vesicular rash (also infects the sensory nerves and moves
retrogradely)→ After resolution of chickenpox, the virus
persists in latent infection in the dorsal root and cranial
nerve ganglia.
• In Zoster, Reactivation in dorsal root, cranial nerve
ganglia
→ travels down axons (anterogradely) → local skin
inflammation innervated by ganglion
Prodromal 2–4-day tingling/localized pain before rash
onset
 Clinical Manifestations of Chickenpox
• Fever, headache, malaise, sore throat, tachycardia. [Prodromal
symptoms]
• A day after the prodromal symptoms start, the characteristic pruritic rash
develops.
• The lesion tends to appear in 3-5 crops in 3-5 days (note: so, Lesions are
typically present in all stages of development at the same time). Crops usually
begin on the trunk, followed by the head, the face, and less commonly, the
extremities (note: they may also appear on the scalp). There may be a total of
100-500 lesions with all different forms being present at the same time.
• Rash features:
• Generalized pruritic, erythematous, vesicular rash (each vesicle is 1-
2mm).
• “Dew drop on rose petal” appearance.
• Formation: macules → vesicles → becomes cloudy → rupture into
ulcerative lesions → scab.
• Vesicles on mucous membranes (e.g. nasopharynx, conjunctive, mouth,
vulva) (note: enanthem)
• Note: Self limited in children, severe in adults (antivirals are indicated)
 Diagnosis
• Clinical.
• Vesicle fluid examination for virus identification under
electron microscope.
• PCR is the current diagnostic method of choice.
• Tzanck smear: scraping of an ulcer base to look for
Tzanck cells (acantholytic cells)
• Detection of varicella-specific antigen in vesicular
fluid by immunofluorescence using monoclonal
antibodies or demonstration of a fourfold antibody
increase of acute and convalescent sera is also
diagnostic but not as sensitive as PCR.
 Treatmen
•
•
t
Itching: cool baths, and application of calamine lotion, promethazine.
Cutting fingernails short and keeping them clean. [rupturing the vesicles by
scratching leads to secondary bacterial infection]
• Note: The parent should be told that the child should not be allowed to scratch/
the lesions as they are itchy since it’ll lead to scarring, especially on the face,
and topical preparations such as calamine are used to reduce itching.
• If the disease develops in an immunocompromised child, urgent admission
for intravenous acyclovir is indicated. [Early therapy with antivirals
(especially within 24 hours of rash onset) in immunocompromised persons is
effective in preventing severe complications, including pneumonia,
encephalitis, and death from varicella.]
• If an immunocompromised child is exposed to someone with the disease, they
should receive prophylaxis with herpes zoster immunoglobulin within 96
hours of the exposure and be monitored closely.
• Isolation (note: the child should be isolated. The infectivity period is how
long the isolation should last, and the incubation period is how long you’ll
be unsure if someone has been infected)
 Antiviral Treatment
Considerations
• Acyclovir or valacyclovir may be considered in those
at risk of severe varicella, such as:
1. Unvaccinated persons older than 12 years
2. Those with chronic cutaneous or pulmonary disease
3. Receiving short-course, intermittent, or
aerosolized corticosteroids
4. Receiving long-term salicylate therapy.
• The dose of acyclovir used for VZV infections is
much
higher than that for HSV.
• It should be started within 24 hours from the onset
of rash and continued for 5 days
Complications of Chickenpox
• Secondary bacterial infection with streptococci,
staphylococci, or any other microorganism. Fever
initially settles down but then recurs a few
days later (note: risk increased if the patient
has been treated with oral corticosteroid or an
NSAID such as ibuprofen[1])
• Encephalitis, often affecting the cerebellum, the child
is ataxic with cerebellar signs. The prognosis is
good.
[other CNS complications are meningitis and intracranial vasculitis]
• Purpura fulminans: this is the consequence of
vasculitis in he skin and subcutaneous tissue.
• Maternal varicella in the first trimester is
associated with congenital malformations in 1-2% of
patients.
 Clinical Manifestations of Shingles
• Note: Age and immunodeficiency have long been 2 of the known
primary risk factors for developing shingles.
• The preeruption phase of zoster includes intense localized and burning
pain and tenderness (acute neuritis) along a dermatome, accompanied
by malaise and fever.
• Children rarely suffer neuralgic pain.
• In several days, the eruption of papules, which quickly vesiculate,
occurs in the dermatome.
• Groups of lesions occur for 1-7 days and then progress to crusting and
healing.
• Thoracic and lumbar dermatomes are most commonly affected.
• Lesions are generally unilaterally and accompanied by regional
lymphadenopathy.
• Shingles in childhood is more common in those who had primary varicella
zoster in the first year of life (note: otherwise, it’s uncommon in children
 Complications of Shingles
• Ramsay Hunt syndrome
• VZV of geniculate ganglion affects facial
nerve; hearing loss, facial weakness
• Postherpetic neuralgia, superinfection of skin
lesions, encephalitis, Mollaret’s meningitis, zoster
multiplex/sine herpete, stroke, myelitis
• Herpes zoster ophthalmicus (sight threatening)
 7. HAND FOOT
MOUTH DISEASE
 Hand Foot Mouth disease
• Note: Herpangina is coxsackie A virus involving the mouth and throat only
• It is a clinical syndrome characterized by oral enanthem and
maculopapular/vesicular rash of the hands and feet.
• It is caused by coxsackie A virus. Incubation period is 3-6 days.
• Signs and symptoms:
• mouth or throat pain secondary to the enanthem. Young children may
refuse to eat.
• Mild fever.
• Oral enanthem: on the tongue and buccal mucosa: erythematous
macules → vesicles with halo of erythema.
• Exanthem: macular, maculopapular, vesicular rash nonpruritic,
usually not painful. Involves the hands (including palms), feet
(including soles), buttocks, legs, and arms.
• Palmer and plantar desquamation 1-3 weeks after presentation.
• Other signs: poor drinking or feeding, feeling cranky, drooling.
• Note: the oral disease could be severe enough to interfere with
eating and drinking; IV fluid may be needed (???)
 Notes
• The virus lives in saliva, mucous and feces.
• Kids aged 1-4 are most likely to get the disease but
adults can get it too.
• There is no vaccine for HFMD. It is self-limited.
• Treatment:
• Paracetamol for fever, mouthwash to numb the pain.
• For blisters: wash with soap and warm water. If it pops,
dab on antibiotic ointment and cover it.
• Prevention: frequent disinfection of the things
that children touch and also HANDWASHING.
• Note: as long as the child is feeling well enough,
they can go to school/daycare
• Watch this
 8.
MENINGOCOCCA
L
MENINGITIS
 Meningococcal Meningitis
• Signs and symptoms include headache, fever, nausea and vomiting,
drowsiness, neck stiffness, intolerance of light and sometimes a blotchy
rash.
• Note: The child is ill
• Meningitis is a medical emergency because if not treated quickly it can lead to
brain damage, blindness, loss of limbs, epilepsy and even death. [though N.
meningitidis has the lowest risk of causing sequelae among the 3 commonest
bacterial meningitis]
• Caused by infection: viral (more common) or bacterial.
• As the infection goes through the outer lining of the brain, it causes cell death
and therefore the inflammation and this in turn cause swelling of the lining of
the brain and this eventually puts pressure on the brain and causes the
symptoms of headache, nausea and drowsiness.
• Neck stiffness occurs due to irritation of the lining when the neck
moves.
• The fever is due to the body’s natural response to the bacterial
infection.
• Watch this
 Meningococcal Meningitis
• The most common cause of bacterial meningitis is meningococcal
meningitis, this is the most dangerous as it causes septicemia as well and is
life-threatening.
• Incubation period: 4 days (range: 2-10 days)
• Meningococcal meningitis often starts insidiously and then may
rapidly become severe and life-threatening.
• The notorious rash is caused by damage to blood vessels (blood leaks out)
causing the classic non-blanching rash (slide test).
• Note: The rash is infectious so you should be careful (???). Blanching should
be done with something transparent like glass.
• The rash is petechial or purpuric (80% of cases), irregular in size and
outline, and may have a necrotic center. The purpura may enlarge rapidly
as the child deteriorates.
• The rash usually develops as a late sign.
• If you SUSPECT meningitis, then start treatment urgently without
waiting for the rash to develop!
• Note: A very rapidly progressing condition, and even minutes matter in
treatment regarding prognosis. If suspected, it should be excluded with
CSF examination and antibiotics should be started urgently.
 Investigations
• Blood tests and culture.
• Imaging
• Lumbar puncture
 Treatmen
• t penicillin once the diagnosis is
Antibiotics: IV or IM
suspected (any febrile child with purpuric rash).
• Arrange rapid admission to hospital and give regular IV
cefotaxime (or any 3rd gen cephalosporin)
• Fluids for shock
• Measures to control fever and pain.
• Vaccination is important although it doesn’t provide protection
against all the strains.
• Prophylactic treatment with rifampicin or ciprofloxacin
(2-day course) to eradicate nasopharyngeal carriage is
given to all household contacts for meningococcal
meningitis and Hib infection.
 Note: Complications
• Brain swelling, raised ICP, Death
• Seizures
• Subdural effusions, Brain abscess, Infarcts
• Hydrocephalus
• Cranial nerve palsies
• Hearing and sight impairments
• Learning disability
• DIC causing tissue necrosis - Amputation of
toes/fingers/limbs
• Cerebral palsy
QUESTIONS
Fever and Rash
Q1. The goals in the treatment of scarlet fever is to prevent
acute rheumatic fever.
A. True
B. False

Q2. Adults with erythema infectiosum may develop joint

pain and stiffness.
C. True
D. False

Q3. The rash of slapped cheek will fade in a matter of few

days.
E. True
anxious or stressed.
comes and goes for up to a month, especially if the patient exercising, hot,
Answer 3: False, the rash fades within 2 weeks, but sometimes body rash

F. False Answer 2: True

Answer 1: True
Doctors who are in contact with a child with
meningococcal meningitis need prophylactic antibiotic.
• True
• False

Treat all close contact with rifampicin. (2 days course)

Answer: True
Answer: False
Uncommon in children; only in those who had a
primary infection in their first year of life.
• False
• True
Shingles never affecting children.
The most common cause of rashes in children is drug
eruption
• True
• False

Answer: False
A characteristic feature of Roseola?
A. Fever coincide with the rash
B. Fever subsides when the rash appears
C. A febrile seizure is present in most
cases
D. Rash is itchy

Answer: B
A single dose of measles vaccine administered to a
child older than 12 months produces protective
immunity in what percentage of individuals?
A. 75%
B. 95%
C. 80%
D. 90%

Answer: B
A red, itchy rash is a well-known characteristic of
rubella virus. Which of the following describes the
progression of this rash?
A. It has a global appearance all over the body
B. It begins on the trunk and spreads peripherally
C. It begins in the extremities and gradually spreads
to
the trunk and face
D. It begins at the hairline and gradually spreads to
the hands and feet

Answer: D
Answer: Rubella – Forchheimer spots on soft palate in 20% of
cases while koplick spots appear on buccal mucosa in measles.
• Measles
• Rubella
What is the cause of this enanthem?
 Case 1
Ari, 9-month-old male.
HPI: Ari presents for evaluation of fever and rash. His
well and was eating and playing normally, so his mother
was not alarmed. After the fever resolved, Ari developed
a red rash on his trunk that progressed rapidly over the
past 24 hours.
PMH: Ari is up-to-date with vaccinations.
Q. Based on Ari’s history and exam, what is the most
likely diagnosis?
Answer:
• Roseola Infantum
1. Type of Micro-Organism:
2. Incubation Period:
3. Transmission:
4. Infectivity:
5. Clinical Features:
6. Rash Characteristics:
7. Diagnosis:
8. Treatment:
9. Complications:
10. Prognosis:
 Case 2
Ashna is a 4-year-old female.
HPI: Previously healthy girl presents with a 1-week history of
cough, runny nose, fever, sore throat and red eyes. She went
to her pediatrician 2 days ago and was prescribed Augmentin
(amoxicillin and clavulanate) for presumed pharyngitis.
Yesterday, Ashna developed a red rash which started on her face
and has spread to her trunk. Her mother would like to know if
the rash is from her new medication.
PMH: Ashna has never received vaccinations due to her
mother’s fear of autism.
Meds: The Augmentin was started 24 hours before the onset of
her rash.
FHx: You also discover that a close family member
recently developed a similar rash.
Physical Exam: Ashna is an ill-appearing child who
presents with a morbilliform rash with erythematous
macules and papules. Lesions have coalesced on the
face and neck. Rash has spread to her trunk and
extremities (not shown). Inspection of mouth reveals,
bluish-white dots on the mucosal surface.
Q. Based on the history and exam, what is the most
likely diagnosis?
Answer:
Measles
1. Type of Micro-Organism:
2. Incubation Period:
3. Transmission:
4. Infectivity:
5. Clinical Features:
6. Rash Characteristics:
7. Diagnosis:
8. Treatment:
9.Complications:
10.Prognosis:
 Case 3
Ameena is a 3-year-old female
HPI: Previously healthy girl her mother noticed a rash covering
her face yesterday when she waked up in the morning today
she noticed that the rash start to appear in her trunk and start to
fade in the face. Her mother would like to know what is the
cause of her rash and whether it is contagious as she is
pregnant in her 2nd trimester.
PMH: Ameena has never received vaccinations due to her
mother’s fear of autism.
FHx: no history of similar rash in family
Meds: The Augmentin was started 24 hours before the onset of
her rash.
Physical Exam: Ameena who presents with a
morbilliform rash with erythematous macules and papules.
Lesions less in the face and neck. Rash has spread to her
trunk and extremities. During the general examination,
you noticed a large lymph node in the right postauricular
region
Q. Based on the history and exam, what is the most
likely diagnosis?
Answer:
Rubella
1. Type of Micro-Organism:
2. Incubation Period:
3. Transmission:
4. Infectivity:
5. Clinical Features:
6. Rash Characteristics:
7. Diagnosis:
8. Treatment:
9.Complications:
10.Prognosis:
The risk for the fetus in case 3 to be affected is 90%
• True
• False

Answer: False
 Case 4
A 7-year-old girl has developed an intensely itchy rash
on her trunk. New spots keep appearing, evolving from a
macule to papules, which then develop a central vesicle
containing fluid. A rash noticed all over the body.
Vaccination history up to date.
Q. Based on this history and exam, what is the most
likely diagnosis?
Answer:
Chicken Pox
1. Type of Micro-Organism: Varicella zoster
2. Incubation Period: 2 week
3. Transmission: Respiratory droplet and direct contact,
4. Infectivity: 2 days before rash until crustation
5. Clinical Features: Fever, vesicular rash
6. Rash Characteristics: Rash is vesicular (itchy),
extends from trunk to extremities, and each lesion is
in a stage (macule, papule, pustule, vesicle, crusts)
7. Diagnosis: Tzanck smear, PCR
8. Treatment: is supportive:
a. Lotion for rash
b. Acetaminophen: for fever
c. Antihistamine: for rash
d. Antiviral: for severe cases
e. VZIG in immunocompromised
9. Complications:
a. Encephalitis
b. Secondary bacterial infection
c. Congenital varicella syndrome
d. Pneumonia
e. Shingles
f. Complication can happen in immunocompromised patients
or pregnancy
10.Prognosis: Good in healthy people generally
 Case 5
Samir, 6-year-old male
HPI: Mother is concerned because he developed low-
grade fevers, painful ulcers in the mouth, and rashes on
his hands and feet.
Meds: No medications, multi-vitamin daily.
PMH: Samir is up-to-date with his vaccinations.
SH: He attends primary school
FHx: No family members with a rash.
Q. What is the most probable diagnosis?
Answer:
Hand Foot Mouth Disease
1. Type of Micro-Organism: Coxsackievirus A16 and
Enterovirus71
2. Incubation Period: 3-7 days
3. Transmission: Saliva, or mucus droplets or feces, contact
with infected individuals
4. Infectivity:
5. Clinical Features: Mouth sore, rashes and blisters on hand
and foot, fever
6. Rash Characteristics: Vesicular in type, Painful subsidies
within few days
7. Diagnosis: in very young children, it is characterized by
change in mood, refusing food and water, drools more. A
throat swab can also be taken.
8. Treatment:
9. Complications:
a. Myocarditis,
b. Non-treatable shock
c. Death
10.Prognosis: Excellent
 Case 6
A 7-month-old boy presented with a 12-hour history of
lethargy and spreading purpuric rash. In the hospital, he
required immediate resuscitation and transfer to
pediatric intensive care for multi-organ failure unit.
The gross edema is from the leak of capillary fluid into
the tissues. He required colloid, inotropic support and
peritoneal dialysis for renal failure.
Q. What is the most probable diagnosis?
Answer:
Meningococcal Septicemia
1. Type of Micro-Organism: Neisseria meningitidis - bacteria
2. Incubation Period: 4 days sometimes ranging between 2-10
days
3. Transmission: The bacteria are transmitted from person-to-
person through droplets of respiratory or throat secretions
from carriers
4. Infectivity:
5. Clinical Features: stiff neck, high fever, sensitivity to light,
confusion, headaches and vomiting. In infants: bulging
fontanelle.
6. Rash Characteristics: characteristic purpuric skin lesion.
Irregular in size, shape and outline. Necrotic center In this
picture the lesion is extensive called “purpura
fulminans”.
7. Diagnosis: blood test, lumbar puncture
8. Treatment: is resuscitation and penicillin. Rifampicin
should be taken for any contacted person for 2 days
as prophylaxis.
9. Complications:
a. Hearing Loss
b. Death
c. …
10.Prognosis: …
 Case 7
7-year-old boy presented with sudden onset of sore throat
since 24 hours and fever of 39 C, abdominal pain, and
one episode of vomiting. No conjunctivitis, no rhinitis,
no cough. Attends primary school and no recent travel.
He is vaccinated.
A rash noticed all over the body looks like sunburn and
feels like sandpaper. After one week the child came to
the clinic with exfoliating skin in his hands.
Q. What is the most probable diagnosis?
Answer:
Scarlet Fever
1. Type of Micro-Organism: Group A, Beta hemolytic
streptococcus
2. Incubation Period: 2-4 days is incubation period
3.Transmission: spreads from person to person via droplets
expelled when an infected person coughs or sneezes
4. Infectivity:
5.Clinical Features: Fever, chills, sore throats, vomiting,
sandpaper, pastia lines, circumoral pallor, exfoliation, white
strawberry tongue first then changes to red strawberry tongue,
follicular tonsillitis
6. Rash Characteristics:
7. Diagnosis: clinically or can be by throat swab
8. Treatment: 10 days penicillin, or alternatively erythromycin
9. Complications:
a. Acute Rheumatic Fever
b. …
10. Prognosis:
 Case 8
Ahmed an 8-year-old male.
HPI: Ahmed was brought to the pediatrician by his
mother because he developed low grade fevers several
days ago, and now has red cheeks and a new rash on his
body.
Meds: No medications
PMH: Ahmed is a healthy child, up to date with
his vaccinations.
Q. What is the most probable diagnosis?
Answer:
Erythema Infectiosum
1. Type of Micro-Organism: Parvovirus B19
2. Incubation Period: 4-14 days incubation
3.Transmission: Transmitting by Respiratory secretions,
vertical from mother to fetus, rarely by blood
transfusion.
4. Infectivity:
5.Clinical Features: Flu-like symptoms, joint pain and
lace-like rash that comes and goes, it’s not necessary to
see rashes through out the period but they may
reappear during exercise or fever or stress lasts up to
weeks.
6. Rash Characteristics:
7. Diagnosis: Clinically diagnosed and can be
diagnosed by blood test in children with known blood
disease or immunodeficient, PCR
8. Treatment: is supportive:
a. Symptomatic reliving.
b. Transfusion for severe anaemia.
c. IVIG in immune compromised.
9. Complications:
a. Aplastic crisis.
b. Trans-placentally cause hydrops fetalis
c. still birth due to severe Anemia
10. Prognosis: