Fever with rash Flashcards

Question

Complications and prognosis

Answer 1

Complications 1. Renal ds – major long term complication (1-2%) 6mos after dx - UA and BP monitoring for several mos after dx Prognosis - Self-limited - 15-60% recur within 4-6 mos

Answer 2

Etiology - Due to TSST-1 producing strains of S.aureus

Answer 3

Patho - TSST-1 act as superantigens w/c trigger cytokine release leading to massive fluid loss and end-organ cellular injury Epid: - Highest rates in menstruating women 15-25 yo (tampon use) - Non-menstrual TSS associated with infected nasal packing and wounds, sinusitis, PN, tracheitis, empyema, burns, abscess, osteomyelitis

Answer 4

CM 1. Acute onset HG fever (>38.8C), diarrhea, vomiting, headache, myalgia 2. Diffuse red macular rash appears within 24 hrs (sunburn like/scarlatiniform) 3. Recovery occurs within 7-10d with desquamation esp of palms and soles 4. Sore throat, mucosal hyperemia, Strawberry tongue 5. Hypotension 6. Involvement of >3 of the ff organ systems: a. GIT: vomiting, diarrhea at onset of illness b. Msk: severe myalgia or CPK >2x the UL of N c. Mucosa: vagina, oropharyngeal, conjunctival hyperemia d. Renal: BUN, crea >2x UL, or >5 wbc/hpf w/o UTI e. Liver: TB, AST, ALT >2x N f. Hema: plt <100K g. CNS: disorientation or alteration in consciousness w/o focal neuro signs when fever and hypotension are absent

Answer 5

CLINICAL Major criteria: Acute fever; temp >38.8C (101.8F) Hypotension (orthostatic, shock, BP below age-appropriate norms) Rash (erythroderma with convalescent desquamation) Minor criteria (Any 3 or more) mucous membrane inflammation (vaginal, oropharyngeal or conjunctival hyperemia, strawberry tongue) vomiting, diarrhea liver abnormalities (bilirubin or transaminase greater than twice upper limit of normal) renal abnormalities (urea nitrogen or creatinine greater than twice upper limit of normal or greater than 5 wbc per HPF muscle abnormalities (myalgia or creatinine greater than twice upper limit of normal CNS abnormalities (alteration in consciousness without focal neurologic signs) Thrombocytopenia (100,000/mm3 or less) Exclusionary criteria Absence of another explanation Negative blood cultures (except occasionally for Staph aureus)

Answer 6

B. Laboratory 1. Cx – usually (-) for blood, throat, CSF 2. CBC – leukocytosis with PMN shift ton the left 3. PBS – mild leukocytosis w/ significant immature neutrophils 4. Elev ALT, CKMM, BUN, Crea, PT, aPTT, hypogly 5. UA – myoglobinuria, hemoglobinuria, sterile pyuria

Answer 7

Mgt 1. Abx: to decrease toxin production Oxacillin 150-200 mkd IV q4/6 x 10-14d Cefazolin 75-100 mkd q8 nafcillin 100-200 mkd q4-6h IV + clindamycin 30-40 mkd q6/8 IV/ IVIG 150-400 mkd x5 d 2. MRSA: vancomycin 40-60 mkd IV q6/8 Prevention - Change tampon q8hWhat

Answer 8

“mucocutaneous LN syndrome/ infantile polyarteritis nodosa” Acute nonspecific systemic vasculitis (medium-sized arteries) § Most common: coronary artery - Leading cause of acquired heart disease in children of developed countries

Answer 9

Epid - Asians, occurs worldwide - M>F 1.5:1 - <5yo (80%) - Unknown cause. Possible infectious/genetic due to: § Young age group affected § Epidemics with wave-like geographic spread § Self-limited acute febrile illness § CM: fever, rash, exanthem, cervical LNE § Asian predilection - Highest risk for CAA: § <6mos § >5yo - Predictors of poor outcome: § Young age § Male § Persistent Fever § Poor response to IVIG § Low WBC, plt, Na, alb § Elev CRP, transaminitis - risk factor: Asian, pacific islander

Answer 10

Patho - Vessels lose its structural integrity and weakens, resulting in dilatation and saccular or fusiform aneurysm formation - Arteritis in coronary and iliac arteries - Interstitial myocarditis, pericarditis, inflamm of SA node and AV conduction system, endocarditis, and valvulitis 3 phases: 1. Neutrophilic necrotizing arteritis – from endothelium to coronary saccular aneurysm. 1st 2 wks. 2. Subacute/chronic vasculitis via lym, plasma cells, eo. Form fusiform aneurysm 3. Progressive sclerosis thrombi: formation in lumen causing occlusion

Answer 11

CM 3 Phases: 1. Acute febrile phase – 1-2wks - Fever 2. Subacute phase – wk 3-5. when fever has abated - Desquamation, thrombocytosis, coronary aneurysms (highest risk of sudden death if with aneurysm) - Lasts until 4th week 3. Convalescent phase – wk 6-8. begins when all clinical signs have disappeared - Until ESR and CRP are normal at 6-8wks after onset Other manifestations: 1. Perineal desquamation (acute phase), periungual desquamation 2. GI: nausea, vomiting, abdominal pain, GB hydrops 3. Cough, colds 4. Significant irritability 5. Arthralgia, arthritis 6. CV: CAA, CHF, myocarditis - CAA develop in 25% untreated at wk 2-3 - Giant CAA: >8mm. pose greatest risk for rupture, MI, stenosis 7. NV: aseptic meningitis, SNHL 8. Urethritis/meatis 9. KD shock syndrome: cardiogenic shock

Answer 12

Dx A. Clinical Fever (HG up to 40C persisting for >5 days, remittent, unresponsive to abx) + >4 of the ff: 1. Bilateral bulbar conjunctival injection w/o exudates 2. Erythema of the oral and pharyngeal mucosa with strawberry tongue, and dry, cracked lips w/o ulceration 3. Nonsuppurative cervical LNE (>1.5cm), usually unilateral 4. Edema and erythema of the hands and feet 5. Polymorphous exanthema: MP, diffuse erythroderma, erythema multiforme-like (nonvesicular and nonpetechial) with accentuation in groin area Fever + <4 criteria or with coronary lesions (echo or angio) still diagnostic, If with >4 fx (esp #4), can be fever of 4 days Incomplete/Atypical Kawasaki Disease - Any infant/child with prolonged unexplained fever with <4 fx AND compatible lab or echo findings B. Lab 1. CBC – anemia, leukocytosis, plt N in 1st week then rapidly inc by 3rd-4th week 2. Elev ESR, CRP 3. 2D Echo – should be done at dx, repeated within wks 2-3, then wks 6-8 4. Dec alb, Na 5. Sterile pyuria 6. Elev transaminase, GGT 7. CSF pleocytosis

Answer 13

Mgt 1. Acute phase - IVIG 2g/kg single IV within 10d of illness onset but ASAP after dx § After 10d: give if i. with persistent fever w/o other explanations ii. CA abN with elev ESR, CRP § ASA moderate dose (30-50 mkd) to high dose (80-100mkd) q6h until afebrile for 48h 2. Convalescent phase - After high dose ASA d/c, low dose ASA (3-5mkd) until no evidence of CA changes 6-8wks after ds onset 3. Long term tx for CA abN - ASA 3-5 mkd OD indefinitely - Clopidogrel 1mkd (max 75mg/d) 4. Cardio referral

Answer 14

Complications 1. Aneurysms CAA 20-25% ASA alone within 10d <5% IVIG+ASA Prognosis - recurs in 1-3% - 50% small CAA return to N by 1-2 yrs

Answer 15

Etiopatho - Group A streptococcus (GAS) - Inflammatory lesion found in the heart, brain, joints and skin - Valvular damage: involves MV> AV> TV, PV - Aschoff bodies in atrium: inflammatory lesions with swelling, fragmentation of collagen fibers, altered staining characteristics of connective tissue - Low risk: <2 per 100,000 school aged children or <1 per 1,000 population - Occurs in 3% of untreated ATP - Worldwide, remains most common form of acquired HD in all age groups - Most important prevention is abx vs GAS pharyngitis - Peak 5-15 yo - Developed countries (<5/100K), developing (100/100K) - Risk factors: FHx, overcrowded, poor sanitation

Answer 16

Patho 1. Cytotoxicity theory – GAS produces Streptolysin O toxin w/c is toxic to cells 2. Immune-mediated pathogenesis/ hypothesis of molecular mimicry – immunologic cross-reactivity between GAS and cardiac cells 3. Pathogenic hypothesis – binding of GAS protein to type IV collagen resulting to heart CM

Answer 17

CM 1. History of streptococcal pharyngitis 1-4 weeks (until 12 wks) before onset of sx 2. Pallor, malaise, easy fatiguability, abdominal pain 2015 Modified Jones Criteria - Detect initial RF only Major manifestation: “CASES” 1. Arthritis (70%) – most common, earliest fx. - often asymmetric, affecting large joints (ankles, wrists, knees, elbows) - low risk: polymigratory polyarthritis - Mod/high risk: monoarthritis, polyarthritis, polyarthralgia - Highly responsive to salicylates, NSAIDs - Self-limited x 2-4 weeks - Inverse relationship with severity of heart involvement 2. Carditis (50%) – most serious manifestation. Only permanent sequelae. Single most important prognostic factor - Clinical (with murmur) or subclinical (no murmur, only echo) - Pancarditis: pericardium, myo, endo § pericarditis: audible friction rub, pericardial effusion § myocarditis: unexplained HF (gallop, soft heart sounds), cardiomegaly (Poor fxn) § endocarditis/valvulitis: apical holosystolic murmur of MR or basal early diastolic murmur. Universal finding. (valvular problem) - hallmark: valvular damage - characteristic fx: MR - apical systolic murmur (AR/MR), resting tachycardia, gallop rhythm, distant/muffled heart sounds, pericardial friction rub, CHF - major conseq = chronic, progressive valvular ds requiring valve replacement 3. Erythema marginatum (<10%) – evanescent, pink rash with pale centers and rounded serpiginous margins - Trunk, inner proximal extremities - Does not occur on the face - Disappear on exposure to cold and reappear after hot shower 4. Subcutaneous nodules (2-10%) – “severity” - Round, hard, painless nonpruritic, freely movable swellings - Symmetrical, singly or in clusters on extensor surfaces of large and small joints, scalp, or spine (legs, olecranon, occiput, interscapular area, elbow) - Lasts for weeks 5. Sydenham chorea (15%) – “chronicity”. “St.Vitus dance/chorea minor” - Purposeless, involuntary, nonstereotypical movt of trunk or ext - after 1-4 wks and lasts 4-18 mos - With muscle weakness and emotional lability - Relapsing grip/Milkmaid’s grip: irregular contraction and relaxation of fingers while squeezing the examiner’s hand - Exacerbated by stress, disappear with sleep - May be standalone criteria

Answer 18

Acute history PE: muffled heart sounds ECG: no signs of changer enlargement 2D echo: valves not thickened, coapting

Answer 19

Chronic history PE: muffled, distinct murmur ECG: with chamber enlargement 2D echo: permanent valvular damage

Answer 20

Minor manifestation: “FARE” 1. Arthralgia (joint pains) a. Low risk: polyarthralgia b. Mod/high risk: monoarthralgia 2. Fever a. Low risk: >38.5C b. Mod/high risk: >38C 3. Elev Acute Phase Reactants a. Low risk: ESR >60 mm/h or CRP >3 mg/dL b. Mod/high: ESR >30 mm/h or CRP >3 mg/dl 4. ECG: Prolonged PR interval PLUS Evidence of antecedent GAS within the last 45d: - Hx of sore throat/scarlet fever unsubstantiated by lab data is inadequate evidence of recent infection - Any 1 of the ff as sign of preceding infection: 1. Elevated or rising ASO or other strep Ab (streptozyme) – most reliable evidence 2. (+) throat culture 3. Rapid antigen test for GAS 4. Recent scarlet fever

Answer 21

Dx: 1. CBC: anemia, leukocytosis 2. Elev ESR, CRP 3. Elev ASO >330 4. Throat CS 5. Streptozyme - measures 5 Ab including anti-DNAseB Ab, antistreptolysin O (ASO) elev 6. 2d echo – valve abN, functional disturbance 7. ECG – sinus tachy, prolonged PR (heart block), low voltage ST changes 8. CXR – N, cardiomegaly, Pulmo congestion

Answer 22

The revised Jones criteria for the dx of RF and RHD 1. Initial RF - Evidence of preceding GAS + § 2 major criteria § 1 major + 2 minor § PLUS evidence of recent strep infection (ASO >330, (+) throat C/S, streptozyme) 2. Recurrent RF - With a reliable past hx of ARF or established RHD, with documented GAS infection § 2 major criteria § 1 major + 2 minor § 3 minor 3 circumstances wherein RF diagnosed without satisfying Jones: 1. When chorea is the only major manifestation 2. When indolent carditis is the only manifestation on first checkup, months after the apparent onset of ARF 3. Apparent ARF in a limited number of patients with recurrences of ARF in high risk populations

Answer 23

Mgt 1. Antibiotics a. Primary prevention (prophylaxis) - To treat strep pharyngitis and eradicate Strep - To prevent first episode of RF - Pen VK 200-500mg qid x 10d - Benzathine penicillin G 0.6-1.2 M U IM SD - Erythromycin 250mg tid x 10d, - Cephalexin 25-100 mkd po q6 - Azithromycin 12 mkd po od x 5d b. Secondary prevention - To prevent recurrences of RF - Prevent colonization and or infection in patients wo have had a previous attack of RF - Penicillin VK 250mg BID q21d - Benzathine penicillin 0.6-1.2 M U q21d IM q21d Duration of prophylaxis 1) RF w/o carditis – 5 yrs after last attack or until 21 yo (whichever is longer) 2) RF w/ carditis, but no valvular ds – 10 yrs after last attack or until 21 yo (whichever is longer) 103 3) RF w/ carditis and persistent valvular ds – 10 yrs after last attack or until 40 yo (whichever is longer, sometimes lifetime) 4) Occupation at risk for GAS – until on job

Answer 24

Etiopatho - Group A beta hemolytic streptococcus (GAS/GABHS) / streptococcus pyogenes pyrogenic producing exotoxin A,B,C § Most common cause of bacterial pharyngitis à RF, GN - Age: 5-15 yo - Produce exotoxin A, B, or C. M protein is an important GAS virulence factor that facilitates resistance to phagocytosis Transmission - Close contact

Answer 25

CM 1. URTI 2. Rash: appear w/in 1-2 d, diffusely blanching, finely papular erythematous producing bright red discoloration which blanches with pressure - starts in the neck, trunk à extremities, exacerbated in creases of elbows, axilla, groin (spares face). - Fades in 3-4d with desquamation downwards - Skin goose-pimple and rough - Red cheeks with pallor around mouth - Scarlatiniform rash – fine, red, papular, “sandpaper” rash of scarlet fever. It begins from the face then becomes generalized. Cheeks are red and area around the mouth is more pale (circumoral pallor-like). Rash blanches with pressure. More intense in the skin creases, esp antecubital fossae, axillae, inguinal creases (Pastia’s lines/Pastia’s sign) 3. (+)tourniquet test/ Rumpel-Leeds phenomenon – capillary fragility can cause petechiae distal to a tourniquet or constriction from clothing 4. Strawberry tongue (white à red) 5. Hyperemic throat 6. Rapid onset significant sore throat 7. Fever >38C 8. Headache 9. Nausea/vomiting, abdominal pain 10. No URTI sx 11. red, enlarged tonsils with exudate, strawberry tongue, palatal petechiae 12. Cervical LNE – swollen, tender, anterior cervical LN

Answer 26

Dx 1. CBC – leukocytosis, WBC 12-16K, 95% PMN. During the 2nd week, 20% with eosinophilia 2. Throat CS 3. PCR, ASO, streptozyme

Answer 27

Mgt 1. Penicillin V 250-500 mg q8/12 po x 10d 2. Amoxicillin 25-50 mkd po q8/12 3. Allergy: Ceph x 10d: Cefuroxime 20-30 mkd po q12 Clindamycin 10-30 mkd q6/8 po erythro/clarith/azith