DEMAM RUAM

Della Rizki Anggilia

18105
 IDENTITAS
• Nama : An. RC
• Jenis Kelamin : Laki-laki
• Tanggal Lahir : 2 Januari 2019
• Usia : 4 bulan 17 hari
• Alamat : Patikraja
• Masuk RS : 16 Mei 2019
 Keluhan Utama
• Batuk pilek
 Assessment Awal Rawat Inap
• Anamnesis:
Keluhan utama: batuk dan pilek
3HSMRS anak nafas cepat, suara nafas grok-grok, saat menetek sering
terputus, demam namun tidak tahu suhunya dan lebih rewel dari
biasanya. 2HMRS ibu membawa ke puskesmas lalu mendapat
paracetamol, anak masih demam suhu 38 derajat, batuk berdahak dan
pilek. Setiap batuk anak sering muntah lendir. HMRS anak sudah tidak
demam namun muncul ruam di seluruh tubuh, tidak diketahui lokasi
awal ruamnya. Terakhir minum paracetamol malam sebelum masuk
rumah sakit.
Pemeriksaan Fisik
Kepala: CA-/-, SI -/-
• Keadaan umum: compos •
Leher: limfonodi tidak teraba
mentis, tampak sesak •
• Thorax: simetris, retraksi (-)
• Tanda Vital • Cor: S1 tunggal, S2 split tak konstan
N : 120x/menit • Pulmo: vesikuler (+), wheezing -/-,
ronkhi (+)
RR : 40x/menit • Abdomen: BU (+) normal, timpani,
supel, hepar dan lien tidak teraba
S : 37,6 0C
• Ekstrimitas: akral hangat, nadi kuat,
SpO2: 98% WPK <2 detik
Integumen : maculopapular
BB: 6,9 kg
•
hiperemis, multiple, terserbar di
wajah, dada, perut dan punggung,
batas tidak tegas, konsistensi seperti
kulit
Assessment
• ISPA
• Exanthema subitum
Plan
• Salbutamol syrup 3x ½ cth
• Paracetamol drops 0.7 cc per 4-6 jam jika demam (dilanjutkan)
• Nebu NaCl 0.9% extra
Introduction
• One of reason parent’s come to hospital
• Non-specific finding, classified based on morphology into
maculopapular rash, generalized diffuse erythema, vesicular,
pustular, nodular, petechial, purpuric, based on distribution into
systemic or localized; symmetric or asymmetric; based on etiology
infectious and non-infectious skin rashes
Diagnostic approach
• History taken: recent travel, contact with animals, medications,
exposure to forest and other natural environment, time of onset,
morphological patterns, seasonal occurrence, etc.
• Knowledge about morphologies, historical data combined with
selective laboratory testing should lead to appropriate
management
• Most of fever with rash in children is caused by viral (self-limited
disease)
• Lab: reactive lymphocytosis and eosinophilia suggest viral and
hypersensitivity reaction respectively.
Maculopapular Rashes
• Most common type of viral infection
• Measles rash (morbili/rubeola): Morbillivirus, rash starts from behind ears
and progresses to the face, followed by neck, torso, extremities over 2-3
days, fever disappears when rash stops evolving. Macular followed by
papular and gradually develops into morbilliform. Rash start to disappear
from face and residual brown skin pigmentation may appear in areas
where rash has faded. Koplik spot (enanthem) appear either 12 h before or
within 24 h of rash appearance.
• Rubella (german measles): progressive from face to body, complete
within hours (much faster than in measles), lighter color, rash fades within
2-4 days, no residual skin pigmentation after fading of rash, can be
prevented by immunization. Maternal infection can cause rubella
congenital.
• Exanthema subitum (roseola, three day fever, 6th disease): HHV-6, fever
lasts for about 3 days, rash appears as soon as fever ends, then spread
to neck, face and extrimities within 24 h and disappeared within 1-2
days, rash usually light rose in color
• Erythema infectiosum (fifth disease): caused by human parvovirus B19,
“slapped cheek”, evolves to a papular rash after macular rash at the
margins of extremities and on the buttocks, start to fade from middle of
the 6th day and disappear on 7th-9th day after first appearance (however
sometimes may recur after few weeks, this usually occur in school-aged
children unlike measles, rubella and roseola.
• Papular-purpuric gloves and socks syndrome (PGSS): caused by
parvovirus B19, may developed by cotrimoxazole antibiotic, skin lesion
develop after clearance of viremia and presence of rising antibody
titers. Usually resolves in 1-2 weeks without any known late sequel
• Pityriasis rosea : acute self-limited disorder, usually in spring and
autumn (seasonal clustering), no definite association of a known
pathogenic virus (suggest HHV-6 and HHV-7). Skin lesion consists of
discrete oval salmon-colored papules and macules, begins with single
herald patch, a week or more before other smaller lesions.
• Unilateral laterothoracic exanthem (asymmetric periflexural
exanthema of childhood) : has erythematous macules or papules that
form morbilliform, scarlatiniform, or eczematous patterns which
begins unilaterally in the axilla or groin, spreads centrifugally, and
usually resolves spontaneously by 4 weeks. The causative agent is
unknown, usually occur during winter and spring. Concomitant
symptoms are fever, sore throat, conjunctivitis, rhinopharyngitis or
diarrhea.
• Eruptive pseudoangiomatosis: small erythematous papules with central
pinpoint vascular supply and surrounding avascular halo. Direct
pressure resulted in complete blanching, and lesions were transient.
May be associated by viral agents, usually self limited.
• Scarlet fever: caused by erythrogenic toxin of Streptococcus pyogens
at the onset of disease. After prodromal symptoms of pharyngitis for
2-3 days, a minute papular rash starts in the axillary region and
inguinal area, and proceeds around the neck and the back, ultimately
spreading to the entire body and shows desquamation one week after
onset, persist for several weeks. In scarlet fever, there are no rashes or
clear findings of upper respiratory inflammation unlike measles and
rubella except area around mouth becomes pale and both cheeks are
red. There is also pastia lines: linear petechial hemorrhages in which
erythema does not disappear when the axillary region, inguinal area,
and antecubital fossa are compressed.
Vesicular rash
• Chicken pox (varicella): rashes spread from the chest to the periphery, and
then to the entire body over the course of about 3 days. Rash patterns
involve the initial appearance of vesicles in a teardrop shape, followed by
simultaneous occurrence of papular and macular rashes with crusting.
These vesicular rashes mostly appear concentrated on the torso, the
extremities, and the head, including the scalp, and can occur on the oral
mucosa accompanied by severe pruritus, and last for 5-6 days; during this
time, the disease remains contagious until crusting is complete, and it is
necessary to isolate patient.
• Herpes zoster: secondary infection by varicella zoster virus, not
common in children. Local rash due to invasion of the virus into local
peripheral nerves. Rarely cause severe pain unlike in adult. If there is
invasion into trigeminal or auditory nerve, can be accompanied by
dizziness or hearing loss. Persist for 5 days or longer.
• Hand-foot-mouth disease: Papular follicles 2-10 mm in size are
accompanied by pain and fever, gastrointestinal symptoms, and local
lymph node enlargement. The lesions mostly occur on the oral
mucosa, the hands, the feet, and buttocks. In rare cases, they might
appear in the nostrils, genitalia, and conjunctiva. This disease can be
spread through direct contact. However, if hand-foot-mouth disease
due to enterovirus type 71 spreads rapidly, paralytic neurological
complications due to encephalitis and spondylitis can appear around
the time that the rash subsides.
• Fungal dermatologic infection: commonly caused by Candida
albicans. Mostly occurs in inguinal and neck which are moist and
creased, it is hard to differentiate from diaper rash and infantile
eczema. However, since the center of the skin lesion is paler than
normal skin, and the outer parts are clearly raised, and as regions of
occurrence gradually spread.
Erythematous rashes
• Urticarial rashes
- History taking: exposure to antibiotics for differentiation between
infectious and non infectious causes.
- Consideration: allergic response to administration of antibiotics or
interaction with sources of infection with antibiotics (mononucleosis
due to EBV)
- Example of bacterial disease with urticarial rash is mycoplasma
infection (appear during treatment of fever respiratiory infection)
- Nonbacterial infectious: lyme disease, enteroviral infection,
adenoviral infection, EBV, hepatitis viral, allergy, etc.
TERIMA KASIH
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