persisterende koorts ondanks antibiotica ALGEMEEN - drug fever - maligniteit: CT-thorax/abdomen - systeemziekte: RF/ANA - maligne neuroleptica syndroom - herhalende infectie (bijv. herhaalde aspiratie) - infectious - drug-resistant organisms - unusual pathogens, eg, - atypisch/Legionella - viruses: CMV/EBV-serologie - fungi: PCP or M.tuberculosis - postobstructive pneumonia, empyema, abscess - superimposed nosocomial - VAP - lijn / infuus - UWI - Clostridium - HIV? B/ lab: LDH/CK, CRP volgen kweken herhalen: BK, evt. sputum medicatie saneren slikken observeren verbreden antibiotica (ciproxin: atypisch, metronidazol: anaeroben, amoxi: enterococ) pneumonie: - X-th herhalen: empyeem? - CT-thorax - bronchoscopy: BAL (maligne cellen, kweek, GM, PJP), biopt lymfocytaire alveolitis: viraal or Chlamydophila - Mantoux - lung biopsy NEUTORPEEN focus? resistentie in inventarisatiekweken? na 48 uur fortum stop bij peni-gebruik geen Augmentin X-thorax, evt sediment, kweken (urine, bloed, CVL, sputum, huidpunctie) mucositis of dentale problemen: metronidazol overweeg: fluconazol blaasjes openen voor virologisch onderzoek geen positieve kweken, ziek en koorts: empirisch vanco-spiegel broxil stop lijn uit ziek, hypotensie, orgaanfalen evidente poortinfectie BK: S.aureus, Candida, Corynebacterium JK, gram negatieve staaf tr <10 of natte purpura eerst 1x tr; wel extra afdrukken (plasmatische stolling corrigeren) BK positief CNS en lijn uit: 2 dagen vanco nabehandelen CNS en lijn niet uit: door tot einde neutropenie AB versmallen levensbedreigend: G-CSF 5 ug/kg persisterend positieve BK: geinfecteerde trombus? 6 weken AB 3 mnden antistolling trombose: lijn uit Rubeola Measles virus -Macular-papular rash that may become confluent; begins on face, neck and shoulders and spreads centrifugally and inferiorly; fades in 4 to 6 days -Most common in children 5 to 9 years of age, nonimmune persons -Prodrome consisting of symptoms of upper respiratory tract infection, coryza, bark-like cough, malaise, photophobia and fever; Koplik's spots (prodromal stage); development of exanthem on fourth febrile day; late winter through early spring - Serology Rubella - Pink macules and papules that develop on forehead and spread inferiorly and to extremities within one day; fading of macules and papules in reverse order by third day - Young adults, nonimmune persons - Prodrome uncommon, especially in children; petechiae on soft palate (Forschheimer's spots); in adults: anorexia, malaise, conjunctivitis, headache and symptoms of mild upper respiratory infection - Serology Erythema infectiosum (fifth disease) - Human parvovirus B19 - Begins as classic bright-red facial rash (“slapped cheek“) and progresses to lacy reticular rash; may wax and wane for 6 to 8 weeks - Children 3 to 12 years of age - Can present as rheumatic syndrome in adults; prodrome of fever, anorexia, rash typically beginning after resolution of fever [ corrected] - Serology Roseola - Human herpes-virus 6 - Diffuse maculopapular eruption, usually sparing face - Children 6 months to 3 years of age - Fever lasting 3 to 4 days, followed within 2 to 3 days by the rash, which resolves spontaneously in several days; almost always a self-limited benign disease; temporal relationship of fever followed by rash is helpful in making the diagnosis - Clinical findings, serology Lyme disease - Borrelia burgdorferi - Macule or papule at site of tick bite, progressing to pathognomonic erythema migrans - all ages at risk for tick exposure in endemic areas - History of tick exposure; secondary erythematous, macular lesions; Borrelia lymphocytoma; highest incidence: May through September - Clinical findings, serology, polymerase chain reaction test Erythema multiforme - idiopathic in 50 percent of cases (see Table 3) - Dull-red macules developing into papules with central vesicles or bullae; common on dorsa of hands, palms, soles, arms, knees, penis and vulva; often bilateral and symmetric - Adults 20 to 30 years of age; men affected more often than women - Major and minor forms; major form always with mucous membrane involvement and usually the result of drug reaction; minor form often associated with herpes simplex outbreak; rarely life-threatening - Clinical findings Secondary syphilis - Treponema pallidum - Various presentations; brownish-red or pink macules and papules; generalized eruption or localized eruption on head, neck, palms or soles; condyloma lata common - Adolescents and adults 15 to 49 years of age; females affected more often than males - Develops 2 to 10 weeks after primary chancre; presents with or without fever; may have generalized lymphadenopathy and splenomegaly; may have recurrent eruptions with symptom-free periods - Dark-field examination, serology Meningococcemia (acute) - Neisseria meningitidis - Variety of lesions but, characteristically, petechial lesions distributed on the trunk and extremities (although the lesions can be located anywhere); petechiae on mucous membranes - Highest incidence in children 6 months to 1 year of age - Acutely ill patient; high fever, tachypnea, tachycardia, mild hypotension; leukocytosis; meningitis develops in more than 50 percent of patients - Often, clinical findings; blood cultures Meningococcemia (chronic) - N. meningitidis - Intermittent maculopapular lesions, often on a painful joint or pressure point; may have nodules on calves - Same as for acute form - Fever, myalgias, arthralgias, headache, anorexia; may recur for weeks or months, with average duration of 8 weeks; may progress to acute meningococcemia, meningitis or endocarditis - Blood cultures Rocky Mountain spotted fever - Rickettsia rickettsii - Rash evolving from pink macules to red papules and finally to petechiae; rash beginning on wrists and ankles and spreading centripetally; involvement of palms and soles late in disease - Young adults with tick exposure; men affected more often than women - Onset typically abrupt; fever, severe headache and myalgias are prominent; rash appearing around fourth day of illness; may have relative bradycardia and leukopenia - Clinical findings, serology Scarlet fever - Beta-hemolytic Streptococcus pyogenes - Punctate erythema beginning on trunk and spreading to extremities, becoming confluent; flushed face with perioral pallor; rash fading in 4 to 5 days and followed by desquamation - Children - Acute infection of tonsils or skin; linear petechiae in antecubital and axillary folds (Pastia's sign); rash appearing 2 to 3 days after infection; initially, “white strawberry tongue” but by fourth or fifth day, “red strawberry tongue” - Rapid strep test, wound or throat culture, antistreptolysin O titers Toxic shock syndrome - Staphylococcus aureus - Diffuse “sunburn“ rash that desquamates over 1 to 2 weeks - All ages, but most common in menstruating females - High fever, hypotension and involvement of three or more organ systems; about 50 percent of cases occurring in menstruating women around onset of menses; postoperative patients at increased risk; condition out of proportion to wound appearance - Clinical criteria, vaginal and wound cultures Kawasaki's disease - Idiopathic - Erythematous rash on hands and feet; morbilliform, scarlatiniform rash on trunk and perineum; hyperemic lips - Children less than 8 years of age, with peak incidence at 1 year; boys affected more often than girls - Winter and spring; high fevers, cervical lymphadenopathy, arthritis, arthralgias, cardiac involvement, mucous membrane involvement; can be complicated by coronary artery abnormalities in 20 to 25 percent of cases - Specific clinical criteria Chickenpox - Varicella-zoster virus - Initially, papules, which evolve into vesicles (“dewdrops on a rose petal”) and eventually into pustules and crusts; rash beginning on face and spreading inferiorly to trunk and extremities - 90 percent of cases in children less than 10 years of age; 5 percent of cases in persons older than 15 years - Prodrome consisting of headache, general aches, backache and malaise is typically absent in children; exposure history; may have all forms of lesions at the same time; vesicles evolving to shallow erosions common on mucous membranes of palate; may also have vesicles on nasal, conjunctival, gastrointestinal tract and genital mucosa - Clinical findings, confirmed by Tzanck test Herpes zoster (shingles) - Varicella-zoster virus - begins as erythematous maculopapular eruption, rapidly evolves to vesicles - all ages, but incidence increases with age and immunosuppression - Prodrome of unusual skin sensations; dermatomal pattern, with lesions rarely crossing midline; pain often severe; more common in thoracic and facial dermatomes - Clinical findings, confirmed by Tzanck test Rickettsialpox - Rickettsia akari - Generalized maculopapular- vesicular exanthem; possible involvement of mucous membranes; no involvement of palms or soles - All ages; urban settings - Transmitted from mice to humans via mites; formation of papules 7 to 10 days after initial bite; typically, formation of a black eschar over healing lesion; febrile phase occurring 3 to 7 days after initial lesion and lasting up to a week; self-limited, usually mild course - Serology Erythema nodosum - Various causes (see Table 4) - Bright-red nodules (3 to 20 cm in diameter) scattered bilaterally but not symmetric; most frequently on lower legs but also found on knees and arms; rarely found on face and neck; lesions often tender and indurated - Adolescents and young adults 15 to 30 years of age; females affected more often than males - Thorough history and physical examination to identify known causes; throat culture for group A beta-hemolytic streptococci; chest radiograph to rule out sarcoidosis; arthralgias present in 50 percent of cases; fever and malaise common - Clinical findings