Download On the basis of the clinical presentation, which disease entity/entities

On the basis of the clinical
presentation, which disease
entity/entities will it be most
compatible with?
Symptoms
• 2 day history of fever, diarrhea, poor oral
intake
• On PE
– Rectal temperature 39.4oC
– BP 80 systolic
– (+) irritability
– Petechial lesions in trunk
Things to consider
• The differential diagnosis will involve an
investigation of historical and epidemiologic
data,
etiologic agent and
a study of the clinical course as to the
–
–
–
presence of prodromal manifestations,
the progress of the rash and the
presence of pathognomonic signs
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
Meningococcemia
• 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
Prognostic indicators for
Meningococcemia
1.
2.
3.
4.
5.
Shock
Hyperpyrexia
Rapid progression of petechial skin lesions
Leukopenia
Absence of CSF pleocytosis
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
2. Dengue Hemorrhagic Fever
•
•
•
•
•
•
Fever
Headache
Muscle and joint pain
Nausea/vomitting
Rash
Hemorrhagic manifestations
Hemorrhagic Manifestations
• Skin hemorrhage:
– Petechiae, pupura,
ecchymoses
• Gum and nose bleeding
• GI bleeding
– Hematemesis, melena,
hematochezia
• hematuria
Dengue Hemorrhagic Fever
T
Lack of appetite
40Flushing
C
Vomiting
Headache
rash
Fall in platelets
Abdominal pain
39
Increased
Muscle/joint pain hematocrit
hemorrhagic
manifestations;
+tourniquet test
Shock
38
37
Rash
36
Day
1
2
3
4
5
6
7
Four criteria for DHF
•
•
•
•
Fever, or recent history of acute fever
Hemorrhagic manifestations
Low platelet count (100,000/mm3 or less)
Objective evidence of “leaky capillaries:”
– elevated hematocrit (20% or more over baseline)
– low albumin
– pleural or other effusions
Clinical Case Definition for Dengue
Shock Syndrome
• 4 criteria for DHF
• Evidence of circulatory failure manifested
indirectly by all of the following:
– Rapid and weak pulse
– Narrow pulse pressure ( 20 mm Hg) OR
hypotension for age
– Cold, clammy skin and altered mental status
• Frank shock is direct evidence of circulatory
failure