1. Case 7: “Pesteng Lamok”

2. “PESTENG LAMOK”  A 7 year old male child has been having fever (maximum 39 0 C) for the past 4 days.This was associated with generalized body malaise, chilliness, headache and muscle pains. A few hours before admission, he complained of severe abdominal pain. Two other classmates were hospitalized earlier for the same complaints.

3. “PESTENG LAMOK”  PE showed a febrile child with RR 26/min.; HR 110/min.; congested posterior pharyngeal walls with several petechiae on the hard palate, few petechiae on the axilla and chest. Chest and abdominal findings were essentially normal. He was given IVF and CBC and platelet counts were requested

4. Guide Questions 1. What conditions will manifest with fever and petechiae/purpura? 2. What is the most likely diagnosis of this patient?

5. Q1: What conditions will manifest with fever and petechiae/purpura? Q1: What conditions will manifest with fever and petechiae/purpura?

6. Fever and Petechiae  Dengue fever & Dengue Hemorrhagic fever  Meningococcemia  Streptococcal pharyngitis  Infective endocarditis  Other viral infections: Infectious mononucleosis, atypical measles, CMV infection and enteroviral infection  Noninfectious causes: drug reaction, Henoch- Schonlein purpura, Hemolytic uremic syndrome and leukemia

7. Q2: What is the most likely diagnosis of this patient?

8. Fever and petechiae  The differential diagnosis will involve an investigation of historical and epidemiologic data, etiologic agent and etiologic agent and a study of the clinical course as to the a study of the clinical course as to the presence of prodromal manifestations, presence of prodromal manifestations, the progress of the rash and the the progress of the rash and the presence of pathognomonic signs presence of pathognomonic signs

9. 1. Meningococcemia  The patients with purpuric rashes often develop septic shock or DIC while patients with macular or petechial rashes are likely to have a better prognosis  Meningeal signs may be present but meningococcemia can occur without meningitis Purpura necrotica Meningococcemia

10. Meningococcemia  In the fulminating case, death occur within hours from overwhelming toxemia and uncontrollable shock –  In the fulminating case, death occur within hours from overwhelming toxemia and uncontrollable shock – (Waterhouse- Friderichsen Syndrome)  Bleeding into internal organs occurs from extensive capillary damage and DIC Adrenal hemorrhage

11. Prognostic indicators for Meningococcemia 1. Shock 2. Hyperpyrexia 3. Rapid progression of petechial skin lesions 4. Leukopenia 5. Absence of CSF pleocytosis

12. Diagnosis  Meningococcemia is suspected from the clinical picture of an acute febrile illness with rapidly progressive purpura involving the skin and mucous membranes esp. with accompanying meningeal signs  Direct film or smear from biopsy of a purpuric lesion on the skin  Definitive diagnosis is achieved by positive blood culture

13. 2. Dengue Fever and Dengue Hemorrhagic Fever