Fever and rash Flashcards by R A

7 year-old female from Cavite, consulted for fever

What are you going to ask in the history?

How well did you know this?

Not at all

Perfectly

HISTORY
1 week PTC, while at school, patient complained of a vague headache. At the clinic, she was noted to have low-grade fever. She was sent home on Paracetamol with only temporary relief of fever.

1 day PTA, patient had fever of 39.8C with associated pink spots on her abdomen and crampy abdominal pain. Fever persisted despite giving two doses of Paracetamol.

Persistent fever and three episodes of diarrhea (greenish, watery, no blood) prompted consult.

PAST MEDICAL HISTORY
Had chicken pox last year, no known allergies, no asthma

FAMILY MEDICAL HISTORY
Unremarkable

BIRTH AND MATERNAL HISTORY
Born full term to a 25-year-old G2P1 mother with unremarkable birth and maternal history.

IMMUNIZATIONS
Completed EPI, given 1 dose of MMR; Hep B, DTap and Hib boosters as a toddler, given influenza vaccine 3 months ago

NUTRITION
Mix-fed, given age-appropriate milk formula
Started complementary feeding at 5 mos
Eats 3 meals a day (has school lunch), eats 2 snacks consisting of junkfood and fishballs from a nearby vendor

DEVELOPMENTAL
At par with age, no problems at school

How well did you know this?

Not at all

Perfectly

What are you going to do in the PE?

PHYSICAL EXAM
Awake, ambulatory but weak, not in distress
BP 105/70, HR 55, RR 20, T 40C
Wt 22 kg (z 0), Ht 130 cm (z +1)
Pink conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy
Equal chest expansion, clear breath sounds, no retractions
Adynamic precordium, loud S1 S2, PMI not displaced, regular rhythm, no murmurs
(+) Pink, non-pruritic macular rash on chest, abdomen and back, flat abdomen, soft, hyperactive bowel sounds, liver edge 2 cm below right costal margin, slightly tender
Pink nail beds, full pulses, no edema, good CRT

How well did you know this?

Not at all

Perfectly

What laboratory exams would you request?

CBC
Urinalysis
EKG
Stool exam
Dengue IgG, IgM
stool culture
blood culture

CBC: Hgb 130, Hct 0.38, WBC 8.5, N 55%, L 41%, M 3%, E 1%, Plt 280

Urinalysis: Yellow, clear, pH 7, SG 1.01, WBC 1/hpf, RBC 0/hpf, glucose none, nitrite negative, protein none, casts none

Stool exam: Greenish brown, mucoid, PMN 5-10, no ova/parasite seen
FOBT: negative

Dengue IgG non-reactive, IgM non-reactive

Stool culture: negative

Blood culture: Growth of Salmonella typhi

How well did you know this?

Not at all

Perfectly

What are the salient features of this case?

[ ] Persistent 1 week fever low > high grade
[ ] Rose spots, abdominal pain and diarrhea
[ ] Bradycardia, rose spots, borborygmi, tender hepatomegaly

How well did you know this?

Not at all

Perfectly

What are the differentials?

*Bacterial (AGE, Typhoid, Shigellosis)

*Viral exanthems (measles, rubella)

*Other viral illnesses (dengue, coxsackie, viral hepatitis)

*Parasitic (amebiasis, schistosomiasis)
Immunologic causes
Kawasaki disease
Scarlet fever
Toxic shock syndrome

How well did you know this?

Not at all

Perfectly

Interpret lab results

How well did you know this?

Not at all

Perfectly

What is the management for this case?

[ ] Emergency measures
[ ] Antibiotics (IV Ceftriaxone 75 mkd, oral Cefixime 15mkd for 7-10 days)
[ ] Preventive measures (handwashing, food preparation, etc)

How well did you know this?

Not at all

Perfectly

Preventive Pediatrics

[ ] Developmental surveillance
[ ] Atopy screen
[ ] Monitor weight, height
[ ] Blood pressure
[ ] Eye exam
[ ] Immunizations
[ ] Deworming (albendazole 400 mg q6mos, mebendazole 500 mg q6mos)
[ ] Dental care
[ ] Nutrition counseling
[ ] Physical activity
[ ] Injury and poisoning prevention
[ ] Child maltreatment prevention
[ ] Counseling on lead and toxicant exposure

How well did you know this?

Not at all

Perfectly

If this is a case of MEASLES, what are the clinical presentation?

3Cs
cough
coryza
conjunctivitis

Enanthem: koplik spots; red lesions with bluish white spots in premolar area; appears before the rash; onset: 1-4 days before rash

Infectious: 3 days before to 4-6 days after rash

Exanthem: Maculopapular lesions –> desquamation
cephalocaudal progression with confluence of rash on face and upper trunk

How well did you know this?

Not at all

Perfectly

If this is a case of MEASLES, what would you request?

CBCPC : dec WBC, inc lymphocytes, low N

Measles IgG, IgM
Measles PCR
ESR, CRP – Normal
Viral culture
Chest xray if prolonged cough

How well did you know this?

Not at all

Perfectly

If this is a case of MEASLES, what are your differentials?

Kawasaki disease
Rubella
EBV
Adeno

How well did you know this?

Not at all

Perfectly

If this is a case of Rubella or German measles, what are the clinical manifestations?

low grade fever
sore throat
red eyes with or without eye pain
headache
malaise
anorexia

rash –> first manifestation
macules coalesce– > centrifugal (face and distal extremities), no desquamation

Enanthem: Forscheimer spots: appears same time as the rash, petechiae/rose colored spots on soft palate

How well did you know this?

Not at all

Perfectly

What is the enanthem for measles?

Koplik spots; red lesions with bluish white spots in premolar area; appears before the rash; onset: 1-4 days before rash

How well did you know this?

Not at all

Perfectly

What is the enanthem for Rubella?

Enanthem: Forscheimer spots: appears same time as the rash, petechiae/rose colored spots on soft palate

How well did you know this?

Not at all

Perfectly

If this is a case of Rubella or German measles, what lab tests will you request?

CBCPC
Rubella IgG, IgM
Rubella RT PCR
Rubella viral culture

What are the clinical findings in Congenital Rubella Syndrome?

IUGR- HC, CC, AC
nerve deafness
salt and pepper retinopathy
cataract
PDA
blueberry muffin rash

What is the risk factor for congenital rubella syndrome?

maternal infection 1st 8 weeks of gestation

What will you request for congenital rubella syndrome?

viral culture using NP secretion, cord blood or placenta
amniotic fluid PCR
Rubella blood IgG + Aliq after 1 month –> Rubella blood IgG2 vs aliq
6 weeks after exposure: rubella blood IgG3 vs aliq
Interpretation: Positive rubella if culture +anytime from 1st extraction

What are the clinical findings in Roseola or exanthem subitum?

high grade fever, fussiness
fever abates after 3 days –> appearance of small pink lesions in the trunk centripetal distribution
rhinorrhea, nasal congestion

rash:morbiliform rash (papules+ macule) trunk– face and extremities without desquamation

mild injection: conjunctiva, throat: Nagayama spot –> ulcers in uvulopalatoglossal junction

What are the clinical manifestations of erythema infectiosum? or 5th disease?

low grade fever
headache
LAD
slapped cheek
reticular lace with central clearing on extensors sparing palms and soles
joint pains: w/ arm stiffness usually in older adolescents

What are the clinical findings in Varicella?

constitutional symptoms: headache, fever, malaise, anorexia and abdominal pain

rash: papular–> vesicualr –>umbilicated (rashes concentrated at trunk centripetal)

Fever usually 24-48 hours before appearance of rash

oral ulcers, vaginal ulcers

transmission of neonatal varicella?

5 days prior to 2 days after delivery
vesicular rashes appear 1st to 2nd week of life

What are the clinical findings of congenital varicella syndrome?

zigzag scarring
limb hypoplasia
microcephaly
seizures
mental retardation
chorioretinitis, microphthalmia, cataracts, hyroureter hydronephros
neurogenic bladder, swallowing dysfunction
aspiration pneumonia
low BW

What are the major and minor criteria of toxic shock syndrome (TSS)?

What are the clinical criteria of Kawasaki disease?

fever atleast 5 days + presence of atleast 4 principal features: 1. changes in extremities Acute: erythema or palms and soles, edema of hands and feet Subacute: periungual peeling of fingers, toes in wk 2 and polymorphous exanthem 2. bilateral bulbar conjunctival injection w/o exudate 3. erythema and cracking of lips, strawberry tongue and/or erythema of oral and pharyngeal mucosa 4.CLAD (>1.5cm) usually unilateral

What diagnostics will you request in Kawasaki disease?

CBCPC- normo normo anemia, thrombocytosis, inc WBC ESR, CRP - elevated 2D echo: aneurysms at least 4mm valvular regurgitation pericarditis myocarditis aortic root enlargement

What is Atypical kawasaki disease?

<4/5 characteristic clinical signs

What are the clinical findings in meningococcemia?

fever irritability lethargy respiratory symptoms refusal to drink vomiting diarrhea limb pain myalgia MPR cold hands and feet prolonged CRT or presence of petechial rash

In meningococcemia, what labs will you order?

CBC PC - H/L WBC, H neutro, anemia, L plt UA- proteinuria, hematuria ESR, CRP - High isolation of organism from blood, CSF, synovial fluid CSF analysis Na/K/Cl low ABG- metabolic acidosis

Give differentials for meningococcemia

sepsis meningitis HSP Bacterial endocarditis measles EBV

What are the clinical findings in HSP?

skin: palpable purpura, subcutaneous edema GI: abdominal pain, nausea, vomiting, diarrhea, intussusception Neuro: HTN, headache Nephro: hematuria, proteinuria, nephrotic syndrome ARF

What lab tests will you request in HSP?

CBCPC- H WBC, mild anemia UA- proteinuria, hematuria BUN, Crea to r/o ARF Whole abdominal UTZ for gastro symptoms skin biopsy renal biopsy

Give differentials for HSP

PSGN HUS SLE

In leptospirosis, what is the appearance of rash>?

transient erythematous maculopapular, uticarial, petechial, purpuric desquamating rash

What are the findings in leptospirosis?

icteric lepto/weil immune phase jaundice acute renal dysfunction -- hematuria, proteinuria, casts, oliguria, anuria pulmonary bleeding cardiovascular collpase

Findings in dengue fever?

fever severe back pain prior to fever onset frontal/retroorbital pain myalgia, arthralgia- occur after onset of fever Day 2-6: fever, nausea, vomiting, anorexia 1-2 days after defervescence --> generalized MPR appears sparing palms and soles; desquamation possible

In dengue, what will you request?

CBC PC- inc HCT, L Plt prolonged BT, dec prothrombin ABG-metab acidosis serum electrolytes ECG sinus bradycardia, ectopic ventricular foci, flat T waves, prolonged PR interval CXR: pleural eff R>L Tornique test