Viral Exanthemshttp://dermnetnz.org/viral/viral-exanthem.htmlCreated 2002.

Last updated
10 Oct 2010 . 2012 NZDSI. You may copy for personal use only. Please refer to our disclaimer and Created 2002. Last updated 10 Oct 2010 . 2012 NZDSI. You may copy for personal use only. Please refer to our disclaimer and copyright policy. copyright policy.

Exanthem is the medical name given to a widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache. It is usually caused by an infectious condition such as a virus, and represents either a reaction to a toxin produced by the organism, damage to the skin by the organism, or an immune response. Exanthems may also be due to a drug (especially antibiotics and nonsteroidal anti-inflammatory drugs). Causes Exanthems during childhood are very common and are usually associated with the following viral skin infections:
y y y y y y y

Common winter and summer viruses including respiratory and enteroviruses respectively Chickenpox (varicella) Measles (morbilli) German measles (rubella) Roseola Fifth disease (erythema infectiosum) Laterothoracic exanthem

Exanthems may also be caused by other bacterial or viral infectious conditions including:
y y y y y y y y

Kawasaki's disease Rickettsial diseases Smallpox (deadly disease hopefully now eradicated by widespread vaccination) Infectious mononucleosis (usually presents as Gianotti Crosti syndrome) Viral hepatitis Scarlet fever Meningococcal disease Staphylococcal toxin infections o Toxic shock syndrome (TSS) o Staphylococcal scalded skin syndrome (SSSS) Streptococcal toxic shock-like syndrome (STSS)

Signs and symptoms Most non-specific rashes appear as spots or blotches and may or may not be itchy. The rash is usually widespread and may be more extensive on the trunk and extremities. In most cases, prior to the rash appearing, patients may have symptoms of general unwellness that include:
y y y

Fever Malaise Headache

y y y y

Loss of appetite Abdominal pain Irritability Muscular aches and pains

These signs and symptoms may vary depending on the cause of the exanthem. See individual causes for details. Viral exanthems often occur in small epidemics so there may be other children effected at the same time. Diagnosis Most common childhood viral exanthems have distinct patterns of rashes and prodromal (prerash) symptoms. If the patient shows classical features of the viral infection then diagnosis is usually clear-cut. However, when there are no characteristic lesions and/or distinctive prodromal signs and symptoms, diagnosis of a specific cause is made more difficult. In addition, some children may only be ill for a very short time and a specific diagnosis may not be possible. It becomes important to make a definitive diagnosis if pregnant women or immunocompromised patients have been exposed to an infected child. However, diagnosis of some causes of exanthems is very important as some of these conditions can become life-threatening if not treated urgently with appropriate medications, e.g. meningococcal disease, Kawasaki's disease. Treatment For most patients with non-specific exanthems no treatment is required as the condition is usually short-lived and resolves spontaneously. If necessary, symptomatic treatment with paracetamol to reduce fever and/or with topical/oral antihistamines or preparations such as calamine lotion to relieve itch may be used. Treatment of specific viral or bacterial exanthems will depend on the cause and is discussed in detail under each individual cause.

Hypersensitivity reactionhttp://www.beltina.org/health-

dictionary/hypersensitivity-reaction-typessymptoms-treatment-allergy.html
A symptomatic interaction between antibodies and allergens that causes an exaggerated and harmful response in the body, commonly called an allergic reaction. Hypersensitivity reactions range from mild to life threatening in severity and symptoms.

ANAPHYLAXIS, the most severe hypersensitivity reaction, is a life-threatening emergency that requires immediate medical attention. There are four types of hypersensitivity reaction, classified according to the way in which the ALLERGEN or ANTIGEN activates the reaction. The classic allergic reaction is the type I hypersensitivity reaction, with exposure to an external substance (the allergen) initiating the IMMUNE RESPONSE. Types II, III, and IV hypersensitivity reactions are endogenous (within the body) responsible for IMMUNE DISORDERS (other than due to IMMUNODEFICIENCY) and AUTOIMMUNE DISORDERS. Type I Hypersensitivity Reaction: IgE Antibody Reaction IMMUNOGLOBULIN E (IgE), the foundation lipoprotein for ANTIBODY formation, mediates type I hypersensitivity reactions. With exposure to an external allergen, the immune response floods the BLOOD circulation with antibodies. Mast cells, basophils, and eosinophils (white blood cells that have specialized immune functions) participate in type I hypersensitivity reactions. Mast cells release HISTAMINE, PROSTAGLANDINS, and other biochemicals that set in motion interactions among various proteins and cells that guide further immune activity. Symptoms generally occur within 15 to 30 minutes of exposure, though sometimes can emerge 10 to 12 hours after exposure. Anaphylaxis (also called anaphylactic shock) is the most severe type I hypersensitivity and is life threatening. ALLERGIC RHINITIS, ALLERGIC CONJUNCTIVITIS, ALLERGIC ASTHMA, ATOPY, and FOOD ALLERGIES are type I hypersensitivity reactions. Type I hypersensitivity reactions tend to run in families, causing researchers to suspect genetic underpinnings for the allergies. A type I hypersensitivity reaction occurs in two stages: the induction stage, the first exposure during which the IMMUNE SYSTEM produces antibodies for the particular antigen or allergen, and the elicitation stage, during which the immune response activates the antibodies to attack the antigen or allergen. There are no symptoms during the induction stage. Each subsequent exposure to the antigen or allergen triggers the elicitation stage, resulting in symptoms. The elicitation stage lasts as long as there is allergen-antibody interaction, though symptoms may continue for some time (hours to days) afterward. Regardless of what form symptoms take (SKIN RASH, tingling around the MOUTH, DIARRHEA), a type I hypersensitivity reaction is a systemic response- it affects and involves the body as a whole. Sensitization to an allergen is long term or lifelong because the antibodybearing PLASMA cells (B-cell lymphocytes that specialize to produce antibodies) circulate indefinitely in the blood. Type II Hypersensitivity Reaction: Cytotoxic Reaction Immunoglobulin G (IgG) and immunoglobulin M (IgM) mediate cytotoxic reactions, also called antibody-mediated hypersensitivity reactions. Type II reactions occur as a result of interactions between antibodies and antigens on cell membrane surfaces. The immune response activates the COMPLEMENT CASCADE, which results in the release of biochemicals that kill the antigen-

bearing cells. Tcell lymphocytes and natural killer (NK) cells also participate. Symptoms of a type II hypersensitivity reaction typically emerge within a few minutes to several hours after antibody-antigen binding. Hemolytic ANEMIA, BLOOD TRANSFUSION reactions, Rhesus (Rh) blood reactions (erythroblastosis fetalis), PEMPHIGUS, GOODPASTURES SYNDROME, and many DRUG allergies (notably penicillin) are type II hypersensitivity reactions. Type III Hypersensitivity Reaction: Immune Complex (IC) Reaction IgG and IgM also mediate type III hypersensitivity reactions, though through different mechanisms from those that occur in type II hypersensitivity reactions. Type III hypersensitivity reactions occur when unattached antigens enter the blood circulation and activate an immune response that results in the formation of an immune complex, a conglomeration of immune proteins (immunoglobulins), platelets, neutrophils, and immune-related substances that surround the antigens. Eventually these clumps fall out of the blood circulation and settle into tissues. Type III antibodies are autoantibodies-that is, antibodies that target the bodys own antigens. Researchers do not know what precipitates the immune response in most type III reactions, though viruses such as HEPATIS A, serum sickness, and drug reactions are sometimes accountable. Symptoms develop 3 to 10 hours after the immune complex forms. ASPERGILLOSIS, SYSTEMIC LUPUS ERYTHEMATOSUS (SLE), GLOMERULONEPHRITIS, polyarteritis and other forms of VASCULITIS, and RHEUMATOID ARTHRITIS are type III hypersensitivity reactions. Type IV Hypersensitivity Reaction: Delayed Reaction T-cell lymphocytes (primarily helper T-cells) mediate type IV hypersensitivity reactions, also called delayed-type hypersensitivity (DTH) or cell-mediated hypersensitivity reactions. Type IV reactions take days to weeks to manifest. The rash of poison ivy, poison oak, and poison sumac represents a type IV hypersensitivity reaction. GRANULOMA is also a typical type IV hypersensitivity reaction, often to BACTERIA or fungi the body is unable to completely eliminate. Common therapeutic applications of a type IV hypersensitivity reaction include the tuberculin skin test to detect the presence of Mycobacterium tuberculosis and skin patch ALLERGY TESTING.

Symptoms and Diagnostic Path Symptoms vary with the type and severity of the hypersensitivity reaction. Itching and skin rash or URTICARIA (hives) are common with type I hypersensitivity reactions. Symptoms may involve the airways (allergic asthma) or gastrointestinal tract (food allergies). Contact reactions typically involve the surface of the skin though may also produce widespread systemic symptoms. The diagnostic path may include blood tests to assess the types and levels of blood

cells present in the circulation as well as to detect the types and quantities of immunoglobulins. Allergy testing can help isolate the specific allergens for type I hypersensitivity reactions. The doctor may conduct further diagnostic testing to rule out other possible causes of the symptoms.

HYPERSENSITIVITY REACTION TYPES AND SYMPTOMS Type of Reaction Symptoms URTICARIA (hives), wheezing itching SKIN RASH, Typical Exposure Onset from

type I (IgE antibodies)

15 to 30 minutes

type II (cytotoxic) type III complex)

redness and swelling due to cell or tissue minutes to several hours death

(immune redness and swelling (erythema and edema) 3 to 10 hours pain hardness (erythema and 48 to 72 hours (nongranuloma) 3 to 4 weeks (granuloma)

redness and type IV (cell mediated) induration) PAIN

Treatment Options and Outlook Antihistamine medications are the most effective intervention early in the onset of a type I hypersensitivity reaction, the classic allergic reaction. These medications block histamine receptors on cell membrane surfaces, effectively breaking the chain reaction effect of the immune response. The longer the hypersensitivity reaction has been under way, the less effective antihistamine medications are because the reaction moves beyond histamine release and binding. Treatment for anaphylactic symptoms is injection with EPINEPHRINE, a potent NEUROTRANSMITTER and HORMONE that effectively halts the immune response. Doctors reserve epinephrine for life-threatening hypersensitivity reactions because the drug has numerous and significant effects on cardiovascular and pulmonary function. CORTICOSTEROID MEDICATIONS are effective for severe type I reactions and type II, III, and IV reactions. Other IMMUNOSUPPRESSIVE MEDICATIONS such as methotrexate and

cyclosporine act through different mechanisms to interrupt the immune response. DISEASEMODIFYING ANTIRHEUMATIC DRUGS (DMARDS) use various mechanisms to achieve similar results. MONOCLONAL ANTIBODIES (MABS) are showing great promise for treating hypersensitivity reactions in some people. The appropriate treatment selections depend on the type and severity of the hypersensitivity reaction and any other health conditions the person may also have.

TREATMENT OPTIONS FOR HYPERSENSITIVITY REACTION Treatments ANTIHISTAMINE MEDICATIONS Effects Effective for Type of Reaction type I

block HISTAMINE binding

CORTICOSTEROID MEDICATIONS

suppress COMPLEMENT CASCADE, type II, type III, type ANTIBODY activation, and eosinophil IV production type I when severe or suppress mast cell release of histamine, nonresponsive to other LEUKOTRIENES, and treatment PROSTAGLANDINS immune response

DISEASE-MODIFYING suppress various ANTIRHEUMATIC DRUGS pathways (DMARDS) EPINEPHRINE injection

type III

stop the immune response immune response

type I when severe or anaphylactic type III and type IV type I when ASTHMA present

immunosuppressive agents suppress various other than corticosteroids pathways

leukotriene receptor antagonist block leukotriene binding medications

MAST CELL stabilizers

prevent degranulation within mast cells type I when asthma to block the release of histamine, present leukotrienes, and prostaglandins block antibody-ANTIGEN binding type I when asthma present

MONOCLONAL

ANTIBODIES (MABS) NONSTEROIDAL INFLAMMATORY (NSAIDS) ANTIDRUGS block the actions of prostaglandins

type III and type IV

type III

Risk Factors and Preventive Measures The sole risk for hypersensitivity reaction (types I, II, and III) is exposure to an allergen; the most effective prevention is avoiding such exposure. This approach is often easier said than done, especially when the allergen is an ubiquitous substance such as pollen or mold. Doctors often recommend taking antihistamine medications on a regular schedule during times when pollen counts are high to reduce hypersensitivity reactions among people who have seasonal allergies. Desensitization effectively reduces or prevents hypersensitivity reactions to specific allergens for many people, providing permanent relief.

Benign Febrile Convulsions in Infants & Childrenhttp://kids-

health-guide.com/febrile-convulsions-feverseizures-in-infants-children.htm
Posted by: | Dr. Lee

Fever is among the most common symptom usually seen in infections and can often be a cause for concern for apprehensive parents. In children, a fever can appear quite suddenly and resolve just as quickly although significantly high temperatures may be recorded during the episode. Although a fever may be a sign of the bodys natural defenses against an infection, there are times when a fever can occur without any clear indication of an infection. High fevers may lead to fits (convulsions), often indicating a need for immediate medical intervention. Febrile convulsions A febrile convulsion is a seizure in young children caused by a sharp rise in body temperature (fever). Febrile convulsions otherwise called febrile seizures (fever seizures) or febrile fits (fever fits) can cause a lot of concern among parents because of its sudden onset and frightening nature.. A convulsion triggered by sudden fever is usually harmless and normally does not indicate a long term or ongoing problem like epilepsy. It is important to note that episodes such as these occur in relation to a rapid rise in temperature, & is not related to the duration of the fever or the degree of temperature. Causes of fever seizures

As previously mentioned, most fever fits occur as a result of a sudden rise in body temperature but it may also develop as the fever is declining. Usually, the fevers that trigger febrile convulsions are caused by an infection in the infants body, such as middle ear infections, or other bacterial or viral infections of the nose & throat. A less common, but more serious cause of such fevers is an infection of the childs brain & spinal cord, such as meningitis. The risk of fever seizures can also increase after some common childhood immunizations. Symptoms of febrile A child experiencing a febrile convulsion may display the following signs and symptoms:
y y y y y y y

A fever, usually higher than 38.9 C Loss of consciousness Jerking of the arms & legs Eyes rolled back in the head Difficulty breathing Vomiting & urinating Crying or moaning

Based on the symptoms, there are two types of febrile convulsions: A simple, benign febrile fits is an episode of convulsions that lasts for less than 10 minutes. The nature of convulsions is generalized in that the entire body goes into spasm or becomes stiff. After the episode of fits subside, the child is normal and suffers no after effects although they may act confused and be quite sleepy. In atypical febrile fits, the episode of convulsions lasts for more than 15 minutes. The nature of convulsions affects only one part of the body and the seizure occurs more than once in 24 hours. The child may show signs of after effects or damage of the brain. Diagnosis Febrile fits is diagnosed by the doctor by careful history taking with due consideration given to the age of the baby and the family history In addition, blood investigations and a lumbar puncture is indicated in special situations to rule out any infection. A lumbar puncture involves taking a sample of fluid that surrounds the spinal cord to look for any signs infection. Treatment When a child starts having fits, parents must remember not to panic. The infant should not be restrained & no attempt should be made to stop the seizure movements. The child should be placed on his or her side to ensure that the airways remain clear and remove any objects or food

from the mouth. Measures must be taken to control the fever & reduce the temperature by removing clothing, applying cool washcloths to the face & back and sponge the rest of the body with cool water. The child must be taken to the doctor when the spell passes. Most febrile seizures stop on their own within a couple of minutes. If the fit last for longer than five minutes, or if the infant has repeated seizures, immediate medical attention is required. Prevention Simple benign febrile fits can be prevented from recurring by taking the following precautions :
y y

As soon as the fever begins, the temperature has to be brought down immediately by paracetamol syrup administration and tepid sponging. Until the child recovers completely from the fever episode, he has to be watched carefully for any sudden rise in temperature.

Hyperpyrexiahttp://www.freemd.com/hyperpyrexi

a/overview.htm
Another name for Hyperpyrexia is Fever.

Fever A person with a fever has an abnormally elevated body temperature over 100.4 degrees F (38 C). Fever can be caused by a variety of conditions. In most cases, it is due to a viral or bacterial infection. The evaluation of fever varies with the age and general health of the patient. Fever is a more worrisome symptom in the patient with a poorly functioning immune system. Symptoms Symptoms depend on the underlying cause for the fever. Common symptoms include excessive sweating, chills, and headache. Other symptoms include body aches, muscle aches, weakness, fatigue, cough, sore throat, rash, and sinus congestion. Treatment Treatment for a fever depends on the underlying cause. Treatment may include rest, encourage fluids, and acetaminophen or nonsteroidal anti-inflammatory medications for fever control. Other treatment measures include antibiotics and antiviral medications. Underlying Cause Fever may be caused by:

y y y y y y y y y y y

Bacterial infections Viral infections Drug side effect Drug toxicity Neurological disease Heatstroke Cancer Autoimmune disease Spinal cord injury Ovulation Hyperthyroidism

Types Fever pattern can be described as:

y y y

Sustained fever: o A consistently elevated body temperature Episodic fever: o A body temperature that cycles up and down Recurrent fever: o Fever returns from time to time with no particular pattern

Fever grade can be described as:

y y

Low-grade fever: o Temperature less than 101 degrees F (38.3 C) High-grade fever: o Temperature over 104 degrees F (40 C)

The following adults should be evaluated by a physician:

y y y

An adult with a fever over 102.9 degrees F (39.4 C) An adult over 65 years old with a fever over 101.9 degrees F (38.8 C) An adult with a fever that lasts longer than 3 days

The following children require an evaluation by a physician:

y y y y y

A child less than 2 months old, who has a fever over 100.4 degrees F (38 C) A child less than 2 years old, who has a fever over 101.9 degrees F (38.8 C) A child less than 2 years old, who has a fever longer than 1 day A child with a fever over 102.9 degrees F (39.4 C) A child with a fever that lasts longer than 3 days

The following infants require an evaluation by a physician:

y y y y y

An infant less than 2 months old, who has a fever over 100.4 degrees F (38 C) An infant less than 2 years old, who has a fever over 101.9 degrees F (38.8 C) An infant less than 2 years old, who has a fever longer than 1 day An infant with a fever over 102.9 degrees F (39.4 C) An infant with a fever that lasts longer than 3 days

Massive Pleural Effusionhttp://www.medicinenet.com/pleural_effusion/article.htmMedical

Author: Benjamin Wedro, MD, FACEP, FAAEM Medical Editor: Charles Patrick Davis, MD, PhD

A pleural effusion is an abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased absorption. It is the most common manifestation of pleural disease. The pleural space is bordered by the parietal and visceral pleurae. The parietal pleura covers the inner surface of the thoracic cavity, including the mediastinum, diaphragm, and ribs. The visceral pleura envelops all lung surfaces, including the interlobar fissures. The right and left pleural spaces are separated by the mediastinum. The pleural space plays an important role in respiration by coupling the movement of the chest wall with that of the lungs in two ways. First, a relative vacuum in the space keeps the visceral and parietal pleurae in close proximity. Second, the small volume of pleural fluid, which has been calculated at 0.13 mL/kg of body weight under normal circumstances, serves as a lubricant to facilitate movement of the pleural surfaces against each other in the course of respirations. This small volume of fluid is maintained through the balance of hydrostatic and oncotic pressure and lymphatic drainage, a disturbance of which may lead to pathology.

Anteroposterior upright chest radiograph shows a massive left-sided pleural effusion with contralateral mediastinal shift. Image courtesy of Allen R. Thomas, MD.

Left lateral decubitus chest radiograph shows fluid layering on the left side, which is not a loculated effusion. Image courtesy of Allen R. Thomas, MD. Precautions Strict precautions are required in the handling of needles and bodily fluids, including pleural fluid. Reports exist of human immunodeficiency virus (HIV) transmission from needles contaminated with pleural fluid. Differentiating Exudate from Transudate Laboratory evaluation of patients with a pleural effusion is directed at first determining if the effusion is an exudate or a transudate. As a consequence, with few exceptions, patients who present with a new pleural effusion should undergo a diagnostic thoracentesis. Subsequent testing is aimed at further identifying the underlying etiology or grading the severity of disease. Depending on the clinical setting, this evaluation may be completed in the emergency department (ED) or initiated in the ED and completed in an inpatient service. The distinction between transudate and exudate is generally made by measurement of serum and pleural fluid lactate dehydrogenase (LDH) and protein concentrations.

Exudates have a higher protein concentration due to increased capillary permeability or decreased lymphatic drainage. As a result, the pleural effusion generally is an exudate if the pleural fluidto-serum total protein ratio is greater than 0.50, the pleural fluid LDH is greater than 0.67 of the upper limits of normal serum LDH, or if the pleural fluidto-serum LDH ratio greater than 0.6 (Light's criteria). Pleural fluid cholesterol also tends to be higher in exudates than in transudates. Further Exudate Analysis Exudative effusions require further laboratory investigation. The pleural fluid should be Analyzed for the following:
y y y y

y y

Cell count with differential Glucose level Amylase level pH - Pleural fluid acidosis, defined as a pH less than 7.30, is seen in a limited number of conditions including empyema; rheumatoid, tuberculous, or lupus pleuritis; malignancy; urinothorax; or esophageal rupture. Cytologic analysis - Especially if malignancy or Pneumocystis carinii is suspected In the appropriate clinical setting, Gram staining, acid-fast bacilli staining, fungal (KOH) staining, and culture and sensitivity for aerobic and anaerobic organisms and fungi

Chest Radiography

Posteroanterior upright chest radiograph shows isolated left sided pleural effusion and loss of left lateral costophrenic angle. Image courtesy of Allen R. Thomas, MD.

Anteroposterior upright chest radiograph shows bilateral pleural effusions and loss of bilateral costophrenic angles (meniscus sign). Image courtesy of Allen R. Thomas, MD.

Chest radiograph, lateral view shows loss of bilateral posterior costophrenic angles. Image courtesy of Allen R. Thomas, MD. A massive effusion is often attributable to an underlying malignancy. Other conditions that must be considered include the following:
y y y y y y y y y y y y y

Congestive heart failure Tuberculosis (TB) Cirrhosis with ascites Transdiaphragmatic rupture of a liver abscess into the pleural space (>90% right-sided) Paragonimiasis (usually unilateral) Peritoneal dialysis (90% right sided) Cryptococcosis Pancreatic pseudocyst Chronic pancreatitis Meigs syndrome Uremic pleuritis Yellow nail syndrome Effects of medications

The location of the pleural effusion can help in the differential diagnosis. Isolated, right-sided pleural effusions commonly occur with the following:
y y y y y y y y

Cirrhosis Peritoneal dialysis Subphrenic or intrahepatic abscess Amebic liver abscess Echinococcal infection Liver transplantation Meigs syndrome Catamenial hemothorax (thoracic endometriosis)

Isolated left-sided effusions occur with the following:

y y y y y y y

Esophageal rupture Pancreatic disease Subphrenic or splenic abscess Splenic infarction Diaphragmatic hernia Pericardial disease Following coronary artery bypass graft surgery