π 2548

REVIEW ARTICLE
31
ow to approach
H"fever
with rash"
·æ∑¬åÀ≠‘ß»√’»ÿ¿≈—°…≥å ‘ß§“≈«≥‘™
∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’
1-5
■Õ“°“√‰¢â√à«¡°—∫º◊Ëπ‡ªìπªí≠À“∑’Ë ”§—≠·≈–æ∫∫àÕ¬„π ■ “‡Àµÿ¢Õ߉¢âÕÕ°º◊Ëπ„π‡¥Á°
‡¥Á° “‡Àµÿ à«π„À≠à‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ‰«√— à«ππâÕ¬‡°‘¥
®“°°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ À√◊Õ·æ⬓ ∫“ß‚√§Õ“°“√‰¡à√ÿπ·√ß
º◊ËπÀ“¬‰¥â‡Õß ·µà∫“ß‚√§°ÁÕ“®Õ—πµ√“¬∂÷ß™’«‘µ‰¥â ·æ∑¬å
§«√ “¡“√∂·¬° “‡Àµÿ¢Õߺ◊Ëπ„À≥ↇæ◊ËÕ„Àâ°“√√—°…“∑’Ë∂Ÿ°
µâÕß
º◊Ëπ„π‡¥Á°Õ“®·∫à߉¥â‡ªìπ™π‘¥µà“ß Ê ‰¥â·°à†maculopapular rash, vesicular rash, petechial rash, erythematous
rash À√◊Õ urticarial rash ‚¥¬æ∫«à“ maculopapular rash
‡ªìπº◊Ëπ∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥1
■ º◊Ëπ maculopapular rash
‚√§„π°≈ÿ¡à π’ºÈ πË◊ ¡’≈°— …≥–§≈⓬°—π ·µà “¡“√∂«‘π®‘ ©—¬
·¬°‚√§‰¥â‚¥¬Õ“»—¬ª√–«—µ‘·≈–°“√µ√«®√à“ß°“¬‡ªì𠔧—≠
‡™àπ ≈—°…≥–¢Õ߉¢â Õ“°“√π”°àÕπ¡’º◊Ëπ Õ“°“√Õ◊Ëπ Ê ∑’Ëæ∫
√à«¡¥â«¬ à«πº≈∑“ßÀâÕߪؑ∫—µ‘°“√„™â‡ªìπ‡§√◊ËÕߙ૬„π°“√
«‘π‘®©—¬∑’Ë·πàπÕπ
ªï∑’Ë 10 ©∫—∫∑’Ë 1
(µ“√“ß∑’Ë 1)
1. °“√µ‘¥‡™◊ÈÕ (infection)
°. °“√µ‘¥‡™◊ÕÈ ‰«√— 2-12 ‡ªì𠓇Àµÿ∑æË’ ∫∫àÕ¬∑’ Ë ¥ÿ ¢Õß
‰¢âÕÕ°º◊Ëπ„π‡¥Á°·∫à߇ªìπ classic viral exanthema ·≈–º◊Ëπ
™π‘¥ nonspecific
(1) Classic viral exanthems º◊Ëπ„π°≈ÿà¡π’È¡’
≈—°…≥–Õ“°“√·≈–Õ“°“√· ¥ß‡©æ“– ‡™àπ À—¥ À—¥‡¬Õ√¡—π
À—¥¥Õ°°ÿÀ≈“∫ ‡ªìπµâπ
À—¥ (measles)6,7 ªí®®ÿ∫—π¡’«—§´’πªÑÕß°—π
À—¥∑’ˉ¥âº≈¥’ ∑”„Àâæ∫À—¥πâÕ¬≈ß à«π„À≠à¡’°“√√–∫“¥„π
ƒ¥ŸÀπ“« À—¥‡ªìπ‚√§∑’˵‘¥µàÕßà“¬¡“° Õ“¬ÿ∑’Ëæ∫∫àÕ¬§◊Õ™à«ß
1-4 ªï Õ“°“√· ¥ß ‡¥Á°®–¡’‰¢â Ÿß ‰Õ¡“° µ“·¥ß ¡’¢’ȵ“
À≈—ß¡’‰¢â 3-4 «—π®–¡’®ÿ¥ ’¢“«∞“π·¥ß¢π“¥ 1-3 ¡¡. ∑’Ë
°√–æÿâß·°â¡ ‡√’¬°«à“ Koplikûs spot ´÷Ë߇ªìπ≈—°…≥–‡©æ“–
¢Õß‚√§™à«¬„π°“√«‘π‘®©—¬‚√§ º◊Ëπ®–‡°‘¥¢÷Èπ„π«—π∑’Ë 4 ¢Õß
‰¢â‚¥¬‡ÀÁπ‡ªìπ discrete erythematous macule & papules
‡√‘¡Ë ®“°∫√‘‡«≥À≈—ßÀŸ°Õà π ®“°π—πÈ ®–≈“¡‰ª∑’µË «— ·¢π ·≈–¢“
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
µ“√“ß∑’Ë 1 “‡Àµÿ¢Õ߉¢âÕÕ°º◊Ëπ„π‡¥Á°
1. Infection
1.1. Viral infection
* Classic viral exanthem
- Measles
- Rubella
- Roseola infantum
- Erythema infectiosum
- Infectious mononucleosis
* Other viral exanthems
- Dengue infection
- Adenovirus, enterovirus
- Gianotti-Crosti disease
1.2. Bacterial infection
- Scarlet fever
- Staphylococcal scalded skin syndrome
- Toxic shock syndrome
- Meningococcemia
- Leptospirosis
1.3. Mycoplasma infection
1.4. Rickettsiae infection
2. Noninfection
2.1. Drug eruption
- Exanthematous drug eruption
- Erythema multiforme
- Stevens-Johnson syndrome
- Toxic epidermal necrolysis
2.2 Collagen vascular diseases
- Systemic lupus erythematosus
- Juvenile rheumatoid arthritis
- Kawasaki syndrome
‡¡◊ËÕº◊Ëπ∂÷߇∑Ⓣ¢â®–≈¥≈ß ´÷Ëß„™â‡«≈“ª√–¡“≥ 48-72 ™—Ë«‚¡ß
º◊ËπÀ“¬‚¥¬‡ª≈’ˬπ‡ªìπ ’¥” (hyperpigment)
‡¥Á°∑’‰Ë ¥â√∫— «—§´’π¡“°àÕπ À√◊Õ‰¥â√∫— ¿Ÿ¡§‘ ¡âÿ
°—π®“°·¡à®–∑”„ÀâÕ“°“√¢ÕßÀ—¥‰¡à√πÿ ·√ß ‡√’¬°«à“ modified
measles Õ“®æ∫ Koplikûs spot À√◊Õ‰¡àæ∫°Á‰¥â
‚√§·∑√°´âÕπ∑’ Ë ”§—≠ ‰¥â·°à ªÕ¥Õ—°‡ ∫
ªï∑’Ë 10 ©∫—∫∑’Ë 1
32
∑âÕ߇ ’¬ ÀŸπÈ”Àπ«° ¡ÕßÕ—°‡ ∫ ‡ªìπµâπ
°“√√—°…“ ‰¡à¡’°“√√—°…“‡©æ“– à«π
„À≠à‡ªìπ°“√√—°…“µ“¡Õ“°“√ ‰¥â·°à °“√„À⬓≈¥‰¢â ¬“·°â
‰Õ ·≈–√–«—ß‚√§·∑√°´âÕπ ‚¥¬‡©æ“–„π‡¥Á°∑’Ë¡’¿“«–∑ÿæ‚¿™π“°“√ Õ“®‡ ’¬™’«‘µ®“°°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬·∑√°´âÕπ
ªí®®ÿ∫π— Õߧ尓√Õπ“¡—¬‚≈° (World Health Organization)
·π–π”„Àâ„™â vitamin A ¢π“¥ 200,000 unit „π‡¥Á°∑’ˇªìπ
À—¥∑’√Ë ∫— ‰«â„π‚√ß欓∫“≈∑ÿ°√“¬À√◊Õ‡¥Á°∑’¡Ë ¿’ “«–∑ÿæ‚¿™π“°“√
À—¥‡¬Õ√¡—π (rubella)7 ‚√§π’Èæ∫∫àÕ¬„π
‡¥Á° ‡°‘¥®“°‡™◊ÈÕ rubella virus ¡—°‰¡à§àÕ¬¡’Õ“°“√π”¡“
°àÕπ ºŸâªÉ«¬¡’‰¢âµË” Ê ª«¥‡¡◊ËÕ¬µ“¡µ—« º◊Ëπ¢÷Èπ∑’ËÀπâ“°àÕπ
·≈â«°√–®“¬Õ¬à“ß√«¥‡√Á«‰ª∑’Ë§Õ ≈”µ—« ·¢π ¢“ º◊ËπÕ¬Ÿà‰¡à
‡°‘π 3 «—π ·≈–À“¬‰¥â‡Õß‚¥¬‰¡à¡’ ’¥” (hyperpigment) °“√
µ√«®√à“ß°“¬æ∫µàÕ¡πÈ”‡À≈◊Õß‚µ∑’Ë∫√‘‡«≥∑⓬∑Õ¬ À≈—ßÀŸ
·≈–µâπ§Õ „𪓰µ√«®æ∫®ÿ¥‡≈◊Õ¥ÕÕ°∑’Ë uvula (Forcheimerûs spot)
°“√√—°…“ ‚¥¬∑—Ë«‰ª‚√§π’ȉ¡à¡’Õ—πµ√“¬
“¡“√∂À“¬‡Õ߉¥â ¬°‡«âπ„πÀ≠‘ß¡’§√√¿å´÷Ëß∂ⓇªìπÀ—¥
‡¬Õ√¡—π„π™à«ß 3 ‡¥◊Õπ·√°¢Õß°“√µ—Èߧ√√¿å Õ“®∑”„Àâ∑“√°
æ‘°“√‰¥â ∂â“ ß —¬§«√‡®“–‡≈◊Õ¥ ‡™àπ hemagglutination
test ‡æ◊ËÕ°“√«‘π‘®©—¬∑’Ë·πàπÕπ
À—¥¥Õ°°ÿÀ≈“∫ (roseola infantum)7 æ∫
∫àÕ¬„π‡¥Á°Õ“¬ÿ 3 ‡¥◊Õπ®π∂÷ß 3 ªï ‡°‘¥®“°‡™◊ÈÕ human
herpesvirus type 6 ‡¥Á°¡’‰¢â Ÿß ‡∫◊ËÕÕ“À“√ √âÕß°«πÀ√◊Õ
‚¬‡¬ ‰¡à‰Õ ‰¡à¡’πÈ”¡Ÿ° µ“‰¡à·¥ß ‰¢â®–¡’Õ¬Ÿàª√–¡“≥ 3 «—π
·≈â«≈¥≈ßÕ¬à“ß√«¥‡√Á« À≈—ß®“°π—Èπ¡’º◊Ëπ¢÷Èπ≈—°…≥–‡ªìπº◊Ëπ
·∫∫ maculopapular rash ¢÷Èπ∑’Ë≈”µ—«°àÕπ ·≈â«°√–®“¬
‰ª∑’ËÀπâ“ ·¢π ¢“ º◊Ëπ®–Õ¬Ÿàπ“π‰¡à‡°‘π —ª¥“Àå ≈—°…≥–
§≈⓬°—∫º◊Ëπ„π‚√§À—¥ ∑”„À♓«∫â“π‡¢â“„®«à“‡ªìπÀ—¥ ·µà‡¥Á°
‰¡à‰Õ ·≈–º◊ËπÀ“¬‚¥¬‰¡à¡’ hyperpigment °“√µ√«®√à“ß°“¬
Õ◊Ëπ Ê æ∫µàÕ¡πÈ”‡À≈◊Õß‚µ∫√‘‡«≥À≈—ßÀŸ ·≈–§Õ
°“√√—°…“ ‚¥¬∑—Ë«‰ª‚√§π’ȉ¡à¡’Õ—πµ√“¬
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
‚√§·∑√°´âÕπ∑’Ë ”§—≠„π™à«ß‰¢â Ÿß ‰¥â·°à ‰¢â·≈â«™—° (febrile
convulsion)
Erythema infectiosum (fifthûs disease)7
‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ human parvovirus B19 æ∫„π‡¥Á°
«—¬‡√’¬π·µàæ∫πâÕ¬„πª√–‡∑»‰∑¬ Õ“°“√ºŸâªÉ«¬¡’‰¢âµË” Ê ¡’
º◊Ëπº‘«Àπ—ß´÷Ëß¡’≈—°…≥–®”‡æ“–§◊Õ¡’º◊Ëπ ’·¥ß∑’Ë∫√‘‡«≥·°â¡
∑—Èß Õߢâ“ß (slapped cheek) 1-4 «—πµàÕ¡“¡’º◊Ëπ·¥ß‡ªìπ
√à“ß·À∑’Ë∫√‘‡«≥·¢π·≈–¢“ (lacy or reticulated erythema)
º◊Ëπ‡ªìπ Ê À“¬ Ê Õ¬Ÿàπ“π 2-3 —ª¥“Àå
°“√√—°…“ √—°…“µ“¡Õ“°“√ ‚√§·∑√°
´âÕπ∑’Ë ”§—≠§◊Õ ª«¥¢âÕ (arthralgia or arthritis) „πºŸâªÉ«¬
immunocompromised host ®–°¥°“√ √â“߇¡Á¥‡≈◊Õ¥·¥ß
(transient reticulocytopenia) À√◊Õ∑”„À⇰‘¥ aplastic crisis „πºŸâªÉ«¬ severe hemoglobinopathies „πÀ≠‘ßµ—Èߧ√√¿å
Õ“®∑”„Àâ∑“√°„π§√√¿å‡ ’¬™’«‘µ‰¥â Ÿß√âÕ¬≈– 5-10
Infectious mononucleosis9 ‡°‘¥®“°‡™◊ÈÕ
Epstein-Barr virus (HHV 4) æ∫∫àÕ¬„π‡¥Á°‚µ „π‡¥Á°‡≈Á°
æ∫‰¥â‰¡à∫àÕ¬ Õ“°“√¡’‰¢â Ÿß 4-14 «—π µàÕ¡πÈ”‡À≈◊Õß‚µ
‡®Á∫§Õ√à«¡°—∫¡’ whitish patch µ—∫¡â“¡‚µ µ“∫«¡ (√âÕ¬≈–
35) µ“‡À≈◊Õß º◊Ëπæ∫‰¥â„π —ª¥“Àå·√°√âÕ¬≈– 10-15
≈—°…≥–‡ªìπº◊Ëπ maculopapular Õ“®æ∫ petechiae, papulovesicular À√◊Õ urticaria °Á‰¥â ∂Ⓣ¥â√—∫¬“·°âÕ—°‡ ∫‚¥¬
‡©æ“–¬“ ampicillin À√◊Õ amoxicillin º◊Ëπ®–æ∫ Ÿß∂÷ß√âÕ¬
≈– 90 ¢ÕߺŸâªÉ«¬ ≈—°…≥–‡ªìπº◊Ëπ·¥ß‡¢â¡∑—Ë«√à“ß°“¬√à«¡°—∫
Õ“°“√§—π
°“√«‘π®‘ ©—¬†®“°Õ“°“√∑“ߧ≈‘π°‘ √à«¡°—∫
º≈°“√µ√«®∑“ßÀâÕߪؑ∫µ— °‘ “√ CBC æ∫ atypical lymphocyte Ÿß„π —ª¥“Àå∑’Ë 2-3 ·≈–„Àâº≈∫«°°—∫ IgM virus
capsid antigen (VCA IgM)
°“√√—°…“ ‰¡à¡’°“√√—°…“‡©æ“– √—°…“
µ“¡Õ“°“√ „π√–¬–‡©’¬∫æ≈—π§«√®–æ—°ºàÕπ„À⇵Á¡∑’Ë Õ“°“√
∑—Ë«‰ª®–¥’¢÷Èπ„π 10-20 «—π ‚√§·∑√°´âÕπ∑’Ë ”§—≠§◊Õ ¡â“¡
ªï∑’Ë 10 ©∫—∫∑’Ë 1
33
¿“æ∑’Ë 1 Denque infection : · ¥ßº◊Ëπ·¥ß ¡’®ÿ¥¢“«µ√ß°≈“ß
(convalescent rash) (¥Ÿ¿“æ ’Àπâ“ 105)
·µ°æ∫‰¥â√âÕ¬≈– 0.5 §«“¡º‘¥ª°µ‘¢Õß√–∫∫ª√– “∑æ∫
‰¥â√âÕ¬≈– 1.5 „π√“¬Õ“°“√√ÿπ·√ß·≈–¡’Õ“°“√¢Õß upper
airway obstruction §«√√—∫‰«â„π‚√ß欓∫“≈ ·≈–„Àâ°“√
√—°…“‚¥¬„Àâ systemic corticosteroids √–¬– —Èπ
Dengue infection3,4 ‡°‘¥®“°‡™◊ÈÕ dengue
virus ºŸâªÉ«¬®–¡’‰¢â Ÿß ‰¡à¡’Õ“°“√‰ÕÀ√◊ÕπÈ”¡Ÿ° ª«¥∑âÕß
Õ“‡®’¬π º◊Ëπæ∫„π«—π∑’Ë 4-5 À≈—ß®“°‰¢â≈¥≈ß ≈—°…≥–‡ªìπ
º◊Ëπ·¥ß ¡’®ÿ¥¢“«µ√ß°≈“ß (convalescence rash) (¿“æ∑’Ë
1) ‚¥¬æ∫∑’Ë·¢π ¢“ ·≈–æ∫®ÿ¥‡≈◊Õ¥ÕÕ°√à«¡¥â«¬ Õ“®æ∫
Õ“°“√§—π√à«¡¥â«¬ °“√µ√«®√à“ß°“¬æ∫µ—∫‚µ °¥‡®Á∫ °“√
µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√ CBC æ∫ hemoconcentration,
atypical lymphocytosis ·≈– thrombocytopenia
°“√√—°…“ µ“¡Õ“°“√ √—°…“¿“«–™ÁÕ°
·≈–‡≈◊Õ¥ÕÕ°
(2) º◊Ëπ™π‘¥‰¡à‡®“–®ß (nonspecific virus)
‡™◊ÈÕ‰«√— Õ◊Ëπ Ê ‡™àπ adenovirus À√◊Õ enterovirus3,10
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
¿“æ∑’Ë 2 Gianotti-Crosti : · ¥ßº◊Ëπ flat-topped monomorphous
papules (¥Ÿ¿“æ ’Àπâ“ 105)
πÕ°®“°‰«√— ∑’Ëæ∫∑”„À⇰‘¥º◊Ëπ∑’Ë¡’Õ“°“√
‡©æ“–·≈â« ‰¢âÕÕ°º◊πË „π‡¥Á°¬—߇°‘¥®“°‡™◊ÕÈ ‰«√— µ—«Õ◊πË Ê ‡™àπ
enterovirus (echovirus, coxsackievirus), adenovirus
´÷ËßÕ“°“√¢Õߺ◊Ëπ„π°≈ÿà¡π’ȉ¡à·πàπÕπ ∂Ⓡ°‘¥®“° enterovirus ‡™◊ÈÕµ‘¥µàÕºà“π∑“߇¥‘πÕ“À“√ º◊Ëπæ∫‰¥âÀ≈“¬™π‘¥ ‡™àπ
morbilliform, petechiae, vesicular, urticaria √à«¡°—∫
Õ“°“√∑“ß√–∫∫∑“߇¥‘πÕ“À“√ ‡™àπ Õ“‡®’¬π ∂à“¬Õÿ®®“√–
‡À≈« œ≈œ
‡™◊ÈÕ adenovirus ´÷Ëß¡—°æ∫„πƒ¥ŸÀπ“« ∑”
„À⇰‘¥º◊Ëπ‰¥â‰¡à∫àÕ¬ ¡—°æ∫√à«¡°—∫Õ“°“√∑“ß√–∫∫∑“߇¥‘π
À“¬„®
º◊πË „π°≈ÿ¡à π’ÕÈ “®µâÕß·¬°®“°º◊πË ·æ⬓™π‘¥
maculopapular†rash†´÷Ëß°“√«‘π‘®©—¬∑’Ë·πàπÕπµâÕßÕ“»—¬
viral culture, serological study À√◊Õ PCR
Gianotti-Crosti disease (papular acrodermatitis of childhood)11,12 ≈—°…≥–º◊Ëπ∑’Ë®”‡æ“–§◊Õ ‡ªìπ
º◊Ëπ flat-topped monomorphous papules ∑’Ë·¢π¢“∑—Èß
Õߢâ“ß Àπâ“ §Õ °âπ ‚¥¬‰¡à¡’∑’Ë≈”µ—« (¿“æ∑’Ë 2) ·≈–
‰¡à¡’Õ“°“√§—π Õ“°“√Õ◊Ëπ∑’Ëæ∫√à«¡¥â«¬‰¥â·°à ‰¢âµË” Ê µàÕ¡
ªï∑’Ë 10 ©∫—∫∑’Ë 1
34
πÈ”‡À≈◊Õß‚µ µ—∫‚µ, anicteric hepatitis ‡¥‘¡‡™◊ËÕ«à“‡°‘¥®“°
‡™◊ÈÕ hepatitis B virus ªí®®ÿ∫—πæ∫«à“‡°‘¥®“°‡™◊ÈÕ enterovirus, EBV, cytomegalovirus À√◊Õµ“¡À≈—ß°“√©’¥«—§´’π
DPT, BCG œ≈œ
°“√«‘π®‘ ©—¬·¬°‚√§µâÕß·¬°®“°‚√§º‘«
Àπ—ßÕ—°‡ ∫ º◊πË ·æâ·¡≈ß ´÷ßË ®–¡’ºπË◊ §≈⓬°—π ·µà„π GianottiCrosti disease ‰¡à¡’Õ“°“√§—π
°“√√—°…“ √—°…“µ“¡Õ“°“√ ‚√§π’ È “¡“√∂
À“¬‡Õ߉¥â„π 3-6 —ª¥“Àå °“√„™â¬“∑“ µ’√Õ¬¥å‰¡à‰¥âº≈
2. °“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬13,14 ‚√§„π°≈ÿà¡π’È®”‡ªìπ
µâÕß„Àâ°“√«‘π‘®©—¬‚√§√«¥‡√Á« ·≈–„Àâ°“√√—°…“∑’Ë∂Ÿ°µâÕß ¡‘
©–π—ÈπºŸâªÉ«¬®–‡ªìπÕ—πµ√“¬‰¥â
Scarlet fever13,14 æ∫∫àÕ¬„π‡¥Á°«—¬‡√’¬π ªí®®ÿ∫—πæ∫‚√§π’ÈπâÕ¬≈߇π◊ËÕß®“°ºŸâªÉ«¬¡—°®–‰¥â√—∫¬“ªØ‘™’«π–
¡“°àÕ𠓇Àµÿ‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ Streptococcus group A
ºŸâªÉ«¬¡’‰¢â Ÿß ª«¥»’√…– ‡®Á∫§Õ ¿“¬„𪓰·¥ß ≈‘Èπ‡ªìπ
ΩÑ“¢“« ‡ÀÁπ papilla ∫«¡·¥ß ‡√’¬° white strawberry
tongue À≈—ß®“°π—Èπ‡ª≈’ˬπ‡ªìπ red strawberry tongue
º◊Ëπª√“°Ø¿“¬„π 1-2 «—πÀ≈—ß®“°¡’‰¢â ≈—°…≥–‡ªìπº◊Ëπ·¥ß
§≈⓬°√–¥“…∑√“¬ (sand-paper like) Àπâ“·¥ß ·µà∫√‘‡«≥
√Õ∫ª“°´’¥ (circumoral pallor) ∫√‘‡«≥¢âÕæ—∫‡ÀÁπ‡ªìπ®ÿ¥
‡≈◊Õ¥ÕÕ°‡√’¬ß‡ªìπ‡ âπ (Pastiaûs lines) À≈—ß®“°º◊ËπÀ“¬®–
¡’°“√≈Õ°¢Õߺ‘«Àπ—߇ªìπ·ºàπ„À≠à¿“¬„π 1 —ª¥“Àå ´÷Ë߇ÀÁπ
™—¥∫√‘‡«≥¡◊Õ ‡∑â“ ≈Õ°‡ªìπ·ºàπ ·µàµ“¡µ—«≈Õ°‡ªìπ¢ÿ¬ ´÷Ëß
‡ªìπ≈—°…≥–®”‡æ“–¢Õß‚√§ (¿“æ∑’Ë 3)
°“√«‘π®‘ ©—¬Õ“»—¬Õ“°“√∑“ߧ≈‘π°‘ √à«¡°—∫º≈
‡æ“–‡™◊ÈÕ„π§Õ ‰¥â‡™◊ÈÕ group A streptococci °“√√—°…“
„À⬓ªØ‘™’«π–§≈ÿ¡‡™◊ÈÕ Streptococcus ‰¥â·°à Pen V 25-50
¡°./°°./«—π π“π 10 «—π À√◊Õ benzathine penicillin
25,000 Àπ૬/°°. ©’¥‡¢â“°≈â“¡‡π◊ÈÕ§√—È߇¥’¬« ‚√§·∑√°´âÕπ
∑’Ë ”§—≠§◊Õ rheumatic fever ·≈– acute glomerulonephritis
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
35
¿“æ∑’Ë 3 Scarlet fever : · ¥ßº◊Ëπ≈Õ°¢Õߺ‘«Àπ—ß (¥Ÿ¿“æ ’Àπâ“
105)
Scarlet fever Õ“®‡°‘¥®“°‡™◊ÈÕ Staphylococcus ´÷Ëߺ◊Ëπ§≈⓬°—∫∑’ˇ°‘¥®“°‡™◊ÈÕ Streptococcus ·µà‰¡à
æ∫§«“¡‡ª≈’¬Ë π·ª≈ß¿“¬„𪓰 ·≈–°“√≈Õ°¢Õ߇™◊ÕÈ Staphylococcus ®–‡√Á«°«à“∑’ˇ°‘¥®“°‡™◊ÈÕStreptococcus
Staphylococcal†scalded†skin†syndrome
(SSSS)13,14 æ∫„π‡¥Á°Õ“¬ÿπâÕ¬°«à“ 5 ªï ‡ªìπ‚√§∑’Ë¡’Õ“°“√
√ÿπ·√ß ‡°‘¥®“° epidermolytic toxin À√◊Õ exfoliative
exotoxin A ·≈– B (ETA & ETB) ¢Õß S. aureus group
2 phage type 55, 71 ´÷Ëß source ¢Õß S. aureus ¡“®“°
nasopharynx –¥◊Õ π—¬π嵓 º‘«Àπ—ß ºŸâªÉ«¬¡’‰¢â Ÿß √âÕß°«π
º◊πË ·¥ß∑—«Ë µ—« (erythroderma) ‡®Á∫∫√‘‡«≥º‘«Àπ—ß (cutaneous
tenderness) ≈—°…≥–∫√‘‡«≥ÀπⓇÀÁπ‡ªìπ periorificial crusting
√Õ∫ª“°·≈–µ“ ´÷Ë߇ªìπ≈—°…≥–‡©æ“–¢Õß‚√§ µàÕ¡“ 24-48
™—Ë«‚¡ß º‘«Àπ—ßæÕ߇ªìπµÿà¡πÈ” (¿“æ∑’Ë 4) °“√µ√«® Nikolskyûs skin „Àâº≈∫«°
°“√«‘π‘®©—¬·¬°‚√§ µâÕß·¬°®“°†toxic
epidermal necrolysis ´÷Ëß∑”„À⇰‘¥º‘«Àπ—ß≈Õ°‡™àπ°—π ·µà
°“√≈Õ°¢Õß SSSS ‡°‘¥„π™—Èπ subgranular layer à«π
ªï∑’Ë 10 ©∫—∫∑’Ë 1
¿“æ∑’Ë 4 Staphylococcal scalded skin syndrome : · ¥ßº◊Ëπ≈Õ°
√Õ∫µ“ ·≈–º◊Ëπº‘«Àπ—ßæÕß·≈–≈Õ°∑’Ë∑âÕß·≈–Õ«—¬«–‡æ»
(¥Ÿ¿“æ ’Àπâ“ 105)
toxic epidermal necrolysis ‡°‘¥°“√·¬°„π™—Èπ dermoepidermal junction
°“√√—°…“ §«√√—∫ºŸâªÉ«¬‰«â„π‚√ß欓∫“≈
„À⬓ªØ‘™«’ π–∑“ßÀ≈Õ¥‡≈◊Õ¥ §≈ÿ¡‡™◊ÕÈ Staphylococcus†‡™àπ
cloxacillin 100 ¡°./°°./«—π π“π 7-10 «—π √–«—ߪí≠À“
°“√ Ÿ≠‡ ’¬πÈ”·≈–‡°≈◊Õ·√à∑“ߺ‘«Àπ—ß √«¡∑—Èß°“√µ‘¥‡™◊ÈÕ∑’Ë
º‘«Àπ—ß °“√¥Ÿ·≈º‘«Àπ—ß ∂Ⓡªìπµÿà¡πÈ”„Àâ wet dressing ¥â«¬
πÈ”‡°≈◊Õ „π√–¬–∑’˺‘«≈Õ°„Àℙ⬓∑“„À⧫“¡™ÿà¡™◊Èπ„À⬓∑“
º‘«Àπ—ß
°“√欓°√≥å‚√§ „π√“¬∑’ˉ¥â√—∫°“√√—°…“
∑’Ë∂Ÿ°µâÕß º◊Ëπ®–À“¬¿“¬„π 10-14 «—π ‚√§·∑√°´âÕπ∑’Ëæ∫
‰¥â·°à °“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ Õ—µ√“°“√µ“¬√âÕ¬≈– 3-5
Toxic shock syndrome13,14 æ∫‰¡à∫àÕ¬„π‡¥Á°
‡ªìπ‚√§∑’Ë¡’§«“¡√ÿπ·√ß·≈–¡’Õ—µ√“µ“¬ Ÿß∂Ⓣ¡à‰¥â√—°…“ ‡°‘¥
®“° toxin ¢Õ߇™◊ÈÕ Staphylococcus (TSST-1 ·≈– TSS-
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
¿“æ∑’Ë 5 Meningococcemia : · ¥ßº◊Ëπ stellate purpura ∑’ˇ∑â“ (¥Ÿ
¿“æ ’Àπâ“ 105)
2) Õ“°“√‡√‘Ë¡¥â«¬‰¢â Ÿß Õ“‡®’¬π ª«¥‡¡◊ËÕ¬µ“¡µ—« ª«¥
»’√…–·≈–¡’§«“¡¥—π‡≈◊Õ¥µË” À√◊Õ„π√“¬√ÿπ·√ßÕ“®¡’Õ“°“√
™ÁÕ°√à«¡¥â«¬ ≈—°…≥–º◊πË ‡ªìπº◊πË ·¥ß∑—ßÈ µ—« (diffuse macular
erythroderma or sunburn rash) ´÷ËßµàÕ¡“ 1-2 —ª¥“Àå
À≈—ß¡’‰¢â º◊Ëπ®–≈Õ°∑—Èßµ—« ‚¥¬‡©æ“–∫√‘‡«≥ΩÉ“¡◊ÕΩÉ“‡∑â“®–
≈Õ°‡ÀÁπ‰¥â™¥— πÕ°®“°º◊πË Õ“®æ∫Õ“°“√¢Õß√–∫∫Õ◊πË Ê √à«¡
¥â«¬ ‡™àπ §≈◊Ëπ‰ â Õ“‡®’¬π °“√∑”ß“π¢Õßµ—∫ ‰µ √–∫∫
ª√– “∑ √–∫∫‡≈◊Õ¥º‘¥ª°µ‘√à«¡¥â«¬ ∂Ⓣ¡à‰¥â√—°…“ºŸâªÉ«¬
Õ“®‡ ’¬™’«‘µ‰¥â
°“√√—°…“ „À⬓ªØ‘™’«π–™π‘¥©’¥§≈ÿ¡‡™◊ÈÕ
Staphylococcus ·≈–√—°…“¿“«–™ÁÕ°
Meningococcemia13,14 ‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ
Niesseria meningitidis Õ“°“√∑“ߺ‘«Àπ—ßæ∫ª√–¡“≥ 2
„π 3 ¢ÕߺŸªâ «É ¬∑’µË ¥‘ ‡™◊ÕÈ meningococcemia À√◊Õ meningococcal meningitis ≈—°…≥–º◊Ëπ‡ªìπ maculopapular rash
À√◊Õæ∫‡ªìπ petechiae À√◊Õ stellate purpura ∫√‘‡«≥·¢π
¢“ ΩÉ“¡◊Õ ΩÉ“‡∑â“ (¿“æ∑’Ë 5) √à«¡°—∫¡’‰¢â Ÿß ª«¥‡¡◊ËÕ¬µ“¡µ—«
ª«¥¢âÕ
°“√«‘π‘®©—¬∑’Ë·πàπÕπ §◊Õ∑” Gram stain
®“°∫√‘‡«≥ hemorrhagic pustules ∂â“æ∫ gram-negative
diplococci Õ¬Ÿà‡ªìπ§Ÿà ®–™à«¬„π°“√«‘π‘®©—¬‚√§ ·≈–¬◊π¬—π
¥â«¬°“√‡æ“–‡™◊ÈÕ®“°‡≈◊Õ¥À√◊ÕπÈ”‰¢ —πÀ≈—ß
ªï∑’Ë 10 ©∫—∫∑’Ë 1
36
°“√√—°…“ „π√“¬ ß —¬°“√µ‘¥‡™◊ÕÈ meningococcal µâÕß√—∫ºŸâªÉ«¬‰«â„π‚√ß欓∫“≈ ·≈–„À⬓ªØ‘™’«π–
∑—π∑’ ‰¥â·°à penicillin ©’¥∑“ßÀ≈Õ¥‡≈◊Õ¥ 200,000 unit/
°°./«—π π“π 7-10 «—π
Leptospirosis13,14 ‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ Leptospira ª√–«—µ‘∑’˙૬„π°“√«‘π‘®©—¬ §◊Õ ºŸâªÉ«¬‰ª‡≈àππÈ”´÷Ëß
—¡º— °—∫Õÿ®®“√–·≈–ªí “«–ÀπŸ∑¡Ë’ ‡’ ™◊ÕÈ π’È Õ“°“√∑’ Ë ”§—≠§◊Õ
‰¢â Ÿß Àπ“« —Ë𠪫¥°≈â“¡‡π◊ÈÕ¡“° µ“·¥ß ª«¥»’√…– §≈◊Ëπ
‰ â Õ“‡®’¬π Õ“®¡’Õ“°“√¢Õß aseptic meningitis À√◊Õ
µ—«‡À≈◊Õß√à«¡¥â«¬ ≈—°…≥–º◊Ëπ‡ªìπ erythematous maculopapular rash
°“√«‘π‘®©—¬Õ“»—¬ª√–«—µ‘ °“√µ√«®√à“ß°“¬
·≈–°“√‡®“–‡≈◊Õ¥À“ titer ¢Õß Leptospira °“√√—°…“„Àâ
¬“ªØ‘™’«π–‰¥â·°à penicillin À√◊Õ tetracycline π“π 7-10
«—π
§. °“√µ‘¥‡™◊ÕÈ †Mycoplasma15 à«π„À≠àæ∫„π‡¥Á°
«—¬‡√’¬π ºŸâªÉ«¬¡’Õ“°“√‰¢âµË” Ê ‰Õ¡“° ≈—°…≥–º◊Ëπ∑’Ëæ∫∫àÕ¬
§◊Õ maculopapular rash ·µà “¡“√∂æ∫º◊Ëπ‰¥â∑ÿ°·∫∫ ‡™àπ
urticaria, vesiculobullous À√◊Õ√ÿπ·√ß®π‡ªìπ StevensJohnson syndrome
°“√«‘π‘®©—¬ ®“°ª√–«—µ‘ °“√µ√«®√à“ß°“¬ ·≈–
°“√µ√«® cold agglutinin ·≈– hemagglutination test
°“√√—°…“ „À⬓ªØ‘™’«π– erythromycin √—∫
ª√–∑“π¢π“¥ 20-50 ¡°./°°./«—π π“π 7 «—π
ß. °“√µ‘¥‡™◊ÈÕ†Rickettsiae14 ‡°‘¥®“°∂Ÿ°‰√ÕàÕπ
°—¥ ∑”„Àⵑ¥‡™◊ÈÕ Rickettsia tsutsugamushi æ∫πâÕ¬„π
‡¥Á° ¡—°æ∫„π endemic area ¢Õ߇™◊ÈÕ ∫√‘‡«≥∑’Ë∂Ÿ°°—¥‡ÀÁπ
‡ªìπ√Õ¬¥”‰À¡âµ√ß°≈“ߧ≈⓬∫ÿÀ√’Ë®’È≈âÕ¡√Õ∫¥â«¬«ß·¥ß
(eschar) ´÷Ëßæ∫∫√‘‡«≥„π√ࡺⓠÀ≈—ß®“°∂Ÿ°‰√ÕàÕπ°—¥‡™◊ÈÕ
‡¢â“ Ÿà°√–· ‡≈◊Õ¥ µàÕ¡“ºŸâªÉ«¬¡’Õ“°“√‰¢â Ÿß†ª«¥»’√…–
ª«¥°≈â“¡‡π◊ÈÕ ‰Õ·Àâß Ê º◊Ëπæ∫„π«—π∑’Ë 5-7 ¢Õß‚√§ ≈—°…≥–‡ªìπ erythematous maculopapular rash ‡ªìπÕ¬Ÿàπ“π
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
3-4 «—π º◊ËπÀ“¬‡Õ߉¥â
°“√«‘π‘®©—¬∑’Ë·πàπÕπ Õ“»—¬°“√µ√«®æ‘‡»…‚¥¬
«‘∏’ Weil-Felix test
°“√√—°…“ „À⬓ªØ‘™’«π– tetracycline À√◊Õ
doxycycline √—∫ª√–∑“ππ“π 7-10 «—π
√ÿª °“√«‘π‘®©—¬·¬°‚√§‰¢âÕÕ°º◊Ëπ„π‡¥Á° µ“√“ß∑’Ë 2
2. º◊πË ®“° “‡ÀµÿÕπË◊ Ê ∑’‰Ë ¡à„™à°“√µ‘¥‡™◊ÕÈ (noninfection)
°≈ÿà¡π’Èæ∫πâÕ¬°«à“°≈ÿà¡·√° ‰¥â·°à
°. º◊Ëπ·æ⬓ (cutaneous drug eruption)16 º◊Ëπ
∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥¢Õß°“√·æ⬓ ‰¥â·°à exanthematous eruption À√◊Õ maculopapular rash ºŸâªÉ«¬¡—°¡’º◊Ëπ¢÷ÈπÀ≈—ß°“√
‰¥â√—∫¬“ª√–¡“≥ 1-2 —ª¥“Àå ¬“∑’ˇªì𠓇Àµÿ∑’Ëæ∫∫àÕ¬
‰¥â·°à ¬“ªØ‘™’«π–„π°≈ÿà¡ penicillin, sulfonamide ·≈–
tetracycline ¬“°—π™—° ‡™àπ phenobarb, dilantin, ¬“≈¥
䢉 (aspirin & nonsteroid anti-inflammatory drugs
(NSAIDs) ‡ªìπµâπ ≈—°…≥–º◊πË ‡ªìπ generalized symmetrical
maculopapular rash ¢÷Èπ∑’Ë≈”µ—« ·¢π¢“ Õ“®¡’Õ“°“√§—π
√à«¡¥â«¬ º◊Ëππ’È·¬°¬“°®“°°“√µ‘¥‡™◊ÈÕ‰«√— „π√“¬∑’Ë ß —¬
§«√´—°ª√–«—µ‘¬“∑’ˉ¥â√—∫¡“°àÕπ¿“¬„π 1-3 —ª¥“Àå°àÕπ¡’
º◊Ëπ¢÷Èπ ∂Ⓣ¡à·πà„®„ÀâÀ¬ÿ¥¬“∑’ËÕ“®‡ªì𠓇Àµÿ ∂Ⓡ°‘¥®“°
·æ⬓ º◊Ëπ®–À“¬¿“¬„π 2-3 «—πÀ≈—ßÀ¬ÿ¥¬“ ∑—Èßπ’È¢÷Èπ°—∫
half-life ¢Õ߬“¥â«¬
°“√µ√«®∑“ßÀâÕߪؑ∫µ— °‘ “√∑’™Ë «à ¬„π°“√«‘π®‘ ©—¬
§◊Õ °“√‡®“–‡≈◊Õ¥ CBC ∂â“æ∫ eosinophils Ÿß„π‡≈◊Õ¥
Õ“®∫Õ°‰¥â«à“‡ªìπ·æ⬓ ·µà∂â“æ∫ atypical lymphocytes
Ÿß™à«¬∫Õ°∂÷ß°“√µ‘¥‡™◊ÕÈ ‰«√— ·µà∫“ߧ√—ßÈ CBC °Á‰¡à “¡“√∂
·¬°‰¥â™—¥‡®π
°“√√—°…“ À¬ÿ¥¬“∑’Ë ß —¬«à“®–‡°‘¥º◊Ëπ ∂⓺ŸâªÉ«¬
§—π„À⬓·°â§—π°≈ÿà¡ antihistamine ‡™àπ chlorpheniramine
À√◊Õ hydroxyzine √—∫ª√–∑“π
ªï∑’Ë 10 ©∫—∫∑’Ë 1
37
Erythema multiforme ·≈– Stevens-Johnson
syndrome ‡ªìπ°≈ÿà¡Õ“°“√ hypersensitivity “‡Àµÿ„π
‡¥Á°Õ“®‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ ‡™àπ virus, Mycoplasma À√◊Õ
Õ“®‡°‘¥Õ“°“√·æ⬓°Á‰¥â†≈—°…≥–º‘«Àπ—ߺ◊πË ‡ªìπ erythematous macule µ√ß°≈“ß¡’ ’‡¢â¡‡√’¬°«à“ target lesions ´÷Ëß
‡ªìπ≈—°…≥–®”‡æ“–¢Õß‚√§ º◊πË æ∫∫àÕ¬∑’·Ë ¢π¢“ ΩÉ“¡◊Õ ΩÉ“‡∑â“
„π√“¬∑’Ë√ÿπ·√ߺ◊Ëπ°√–®“¬∑—Ë«µ—«
„π√“¬∑’˺ŸâªÉ«¬¡’‰¢â√à«¡°—∫¡’§«“¡º‘¥ª°µ‘
¢Õ߇¬◊ËÕ∫ÿ¿“¬„π√à“ß°“¬¡“°°«à“ 2 ·Ààß ‡™àπ ∑’ˇ¬◊ËÕ∫ÿπ—¬π嵓
ª“° Õ«—¬«–‡æ» ∑«“√Àπ—° ‡√’¬°«à“ Stevens-Johnson
syndrome
°“√√—°…“§◊Õ æ¬“¬“¡À“ “‡Àµÿ¢Õß‚√§ ·≈–
√—°…“µ“¡Õ“°“√ ∂Ⓡªìπ erythema multiforme º◊Ëπ®–À“¬
¿“¬„π 1-2 —ª¥“Àå ·µà∂Ⓡªìπ Stevens-Johnson syndrome µâÕß√—∫‰«â„π‚√ß欓∫“≈ √–«—ߪí≠À“‡√◊ËÕß‚√§·∑√°
´âÕπ∑’˺‘«Àπ—ß ∂â“ “‡Àµÿ‡°‘¥®“°°“√·æ⬓ °“√„Àâ corticosteroids†√—∫ª√–∑“πÀ√◊Õ©’¥„π√–¬– —Èπ Ê ·≈–„Àâ„π√–¬–
·√°¿“¬„π 5 «—π ®–‰¥âº≈¥’
Toxic epidermal necrolysis15 ‡ªìπ°≈ÿà¡Õ“°“√
·æ⬓∑’Ë√ÿπ·√ß∑’Ë ÿ¥ “‡Àµÿ‡°‘¥®“°·æ⬓ªØ‘™’«π– ‡™àπ sulfonamide, tetracycline À√◊Õ¬“°—π™—° (phenobarb À√◊Õ
dilantin) ºŸâªÉ«¬®–¡’‰¢â √–¬–·√°¡’º◊Ëπ·¥ß∑—Ë«µ—« µàÕ¡“º‘«
Àπ—ß≈Õ°§≈⓬°—∫ºŸâªÉ«¬∂Ÿ°πÈ”√âÕπ≈«° ·≈–¡’Õ“°“√°¥‡®Á∫
(skin tenderness) ∂⓵√«® Nikolskyûs sign ®–„Àâº≈∫«°
´÷ËßµâÕß·¬°°—∫ staphylococcal scalded skin syndrome
(SSSS) ´÷Ë߇°‘¥®“°°“√µ‘¥‡™◊ÈÕ ‚√§π’ÈÕ—µ√“µ“¬ Ÿß∂÷ß√âÕ¬≈–
25-50 ®“°°“√µ‘¥‡™◊ÈÕ·∑√°´âÕπ ·≈–§«√√—∫ºŸâªÉ«¬Õ¬Ÿà„π
burn unit À√◊Õ ICU „ÀâπÈ”‡°≈◊Õ·√à„Àâ‡æ’¬ßæÕ ¥Ÿ·≈º‘«
Àπ—߉¡à„Àⵑ¥‡™◊ÈÕ·∑√°´âÕπ √–«—ß¿“«–‰µ«“¬·≈–µ‘¥‡™◊ÈÕ„π
°√–· ‡≈◊Õ¥
¢. Collagen vascular diseases17
Systemic lupus erythematosus (SLE)16 æ∫
º‘ « À π— ß
15
‡¡…“¬π 2548
Fever, URI
symptoms
Young
children/
adolescents
1-6 yrs
Epstein-Barr
exanthems
(Epstein-Barr virus)
Gianotti-Crosti syn
(hepatitis B,
coxsackie, EBV,
etc.)
Usually absent
Any season
Papules/
papulovesicles,
may become
confluent
Fever, adenopathy, Maculopapular or
sore throat
morbilliform
Rubelliform,
morbilliform,
roseola-like
Maculopapular
rash appears after
fever declines
last hours to days
Extremely variable,
maculopapular,
petechial,
purpura, vesicular
Slapped cheeks;
reticulate erythema
or maculopapular
Erythematous
macules and
papules, become
confluence
Rose pink papules
not confluent
Morphology
Any season
Winter/spring
5 mos-5 yrs
Adenovirus
exanthems
(adenoviruses)
Usually none
Fever
(occasional)
6 mos-3 yrs
Roseola
(herpesvirus 6)
Winter/spring
Absent or low
grade fever,
malaise
Enterovirus
Young children Summer/fall
exanthems
(coxsackie, echo,
other enteroviruses)
5-15 yrs
Erythema
infectiosum
(parvovirus B19)
Spring
High fever, URI,
conjunctivitis
High fever
3-5 days
Adolescents/
young adults
Rubella
(rubella virus)
Winter/spring
Spring/fall
Infants to
young adults
Measles
(rubeola virus)
µ“√“ß∑’Ë 2 °“√«‘π‘®©—¬·¬°‚√§‰¢âÕÕ°º◊Ëπ„π‡¥Á° : °“√µ‘¥‡™◊ÈÕ
Diseases (cause) Usual age
Season
Prodrome
Face, arms, legs,
buttocks, spares
torso
Trunk, extremities
Generalized
Usually
generalized,
may be acral
Occasional
lymphadenopathy,
hepatomegaly,
splenomegaly
Low grade fever,
occasional
myocarditis,
aseptic meningitis,
pleurodynia, malaise
Fever, URI
symptoms,
occasionally
pneumonia
Cervical adenopathy,
liver/spleen enlarged
Special management
Clinical
hepatitis B and
EB serologies
Mono-spot EBV-IgM
acute/conv
Usually clinical,
viral culture from
throat, rectal
swabs in selected
cases
Viral isolation or
acute/conv serology
Usually clinical
Usually clinical;
acute/conv serology
Rubella IgM or
acute/conv HAI
serology
If petechiae or
purpura, must
consider
meningococcemia
Report to public
health; check for
exposure to
pregnant women
Clinical; acute/
Report to
conv hemagglutinin public health
(HAI) serology
Associated findings Diagnosis
Koplikûs spots,
toxic appearance,
cough, adenopathy,
fever
Postauricular and
occipital
adenopathy;
headache, malaise
Usually arms/legs; Rash waxes/wanes
may be generalized several weeks;
occasional arthritis,
headache, malaise
Trunk, neck, may Cervical and
be generalized,
postauricular,
adenopathy
Begins on face
and moves
downward over
whole body
Begins on face
and moves
downward
Distribution
<2
6 mos-6 yrs
Meningococcemia
(meningococcus)
Kawasaki disease
(cause unknown)
Winter/spring
Winter/spring
Fall to spring
Irritability
Malaise, fever,
URI
symptoms
Acute onset
with fever,
sore throat
Polymorphouspapular,
morbilliform,
erythema with
desquamation
Papules, petechiae,
purpura
Diffuse erythema
with sand-paper
texture
Generalized, often
with perineal
accentuation
Facial flushing
with circumoral
pallor, linear
erythema in skin
folds
Trunk, extremities,
palms, soles
Temp > 40° C
meningismus
circulatory
collapse
Conjunctivitis,
cheilitis, glossitis
peripheral edema,
adenopathy
Exudative
pharyngitis,
palatal petechiae,
abdominal pain
Hypotension; fever,
myalgias,
diarrhea/vomiting
Macular
erythroderma
Generalized
Associated findings
Fever,
conjunctivitis,
rhinitis
Morphology
Distribution
Abrupt onset,
Diffuse with
tender erythroderma perioral, perinasal
scaling
Clinical blood
Immediate IV
culture, spinal tap penicillin in ER,
treat shock, if
present
Clinical
Admit to hospital for
IV gamma globulin,
salicylate
Special management
Neonate; if blistering
present, hospitalize
for IV cloxacillin
and fluid/electrolyte
treatment
Clinical case
Treatment of
definition criteria hypotension, admit
isolation S. aureus, to hospital,
cervix, etc.
antibiotics to
eradicate staph
Throat culture
Penicillin IM or
PO penicillin or
erythromycin
Diagnosis
Clinical, cultures
of S. aureus from
distant site
Sx = symptoms, URI = upper respiratory infection, Conv = convalescent, ER = emergency room, staph = staphylococci
Adapted from : Williams ML, Frieden I. Dermatologic disorders. In: Grossman M, Dieckmann RA, editors. Pediatric emergency medicine: a clinicianûs reference. Philadelphia: JB Lippincott; 1991.
yrs
School-aged
children
Scarlet fever
Streptococcus
µ“√“ß∑’Ë 2 °“√«‘π‘®©—¬·¬°‚√§‰¢âÕÕ°º◊Ëπ„π‡¥Á° : °“√µ‘¥‡™◊ÈÕ (µàÕ)
Diseases (cause) Usual age
Season
Prodrome
Staph scalded
Neonates and Any season
None
skin syndrome
infants
(S. aureus/
epidermolytic
toxin)
Toxic shock
Adolescents/ Any season
None
syndrome (staph young adults
toxin)
REVIEW ARTICLE
40
¿“æ∑’Ë 6 Kawasaki syndrome : · ¥ß≈—°…≥–ª“°·¥ß ·Àâß·µ° ·≈–°“√≈Õ°∑’˪≈“¬π‘È«¡◊Õ (¥Ÿ¿“æ ’Àπâ“ 105)
∫àÕ¬„πºŸâªÉ«¬‡¥Á°‚¥¬‡©æ“–‡æ»À≠‘ß ºŸâªÉ«¬¡’Õ“°“√‰¢â√à«¡
°—∫º◊Ëπ‡ªìπ Ê À“¬ Ê ≈—°…≥–º◊Ëπ∑’Ëæ∫„πºŸâªÉ«¬†SLE†¡’‰¥â
À≈“¬·∫∫ µ—Èß·µàº◊Ëπ·∫∫‰¡à®”‡æ“– ‡™àπ maculopapular
rash, urticaria ®π∂÷ߺ◊Ëπ∑’Ë®”‡æ“– ‡™àπ malar rash, discoid
LE, vasculitis À√◊Õ photosensitivity Õ“°“√Õ◊Ëπ Ê ∑’Ëæ∫
√à«¡¥â«¬ ‡™à𠪫¥¢âÕ º¡√à«ß ´’¥ ·º≈„𪓰 µàÕ¡πÈ”
‡À≈◊Õß‚µ Õ“°“√∑“ߪ√– “∑ ·≈–‰µ ‡ªìπµâπ
°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√∑’˙૬„π°“√
«‘π‘®©—¬§◊Õ °“√∑” ANA profile, LE cell
°“√√—°…“ ¬“∑’Ë„™â„π°“√√—°…“ ‰¥â·°à prednisolone ´÷Ëß¢π“¥¢Õ߬“¢÷Èπ°—∫§«“¡√ÿπ·√ߢÕß‚√§ ·≈–
§«“¡º‘¥ª°µ‘¢ÕßÕ«—¬«–¿“¬„𠇙à𠉵 À—«„® ¡Õß √–∫∫
‡≈◊Õ¥
Juvenile rheumatoid arthritis (JRA)17 ≈—°…≥–
¢Õߺ◊πË „π‚√§π’È ¡’≈°— …≥–‡©æ“–§◊Õ º◊πË ·∫∫ maculopapular
rash ‡ÀÁπ‰¥â™—¥‡«≈“‰¢â Ÿß ·µà∂Ⓣ¢â≈¥≈ß º◊Ëπ®–À“¬‰ª æ∫
∫àÕ¬„π JRA ™π‘¥ systemic onset type Õ“®¡’Õ“°“√¢Õß
hepatosplenomegaly µàÕ¡πÈ”‡À≈◊Õß‚µ °“√«‘π‘®©—¬Õ“»—¬
ªï∑’Ë 10 ©∫—∫∑’Ë 1
ª√–«—µ‘ µ√«®√à“ß°“¬ ·≈–·¬° “‡ÀµÿÕ◊Ëπ Ê ¢Õ߉¢â·≈–º◊Ëπ„π
‡¥Á°
°“√√—°…“„Àâ aspirin 80-100 ¡°./°°./«—π
∂Ⓣ¡à‰¥âº≈Õ“®æ‘®“√≥“„Àâ nonsteroid anti-inflammatory
drugs (NSAIDs) À√◊Õ„π√“¬Õ“°“√√ÿπ·√ßÕ“®„Àâ prednisolone √—∫ª√–∑“π√à«¡¥â«¬
Kawasaki syndrome18 (¿“æ∑’Ë 6) ‡ªìπ‚√§∑’Ë
æ∫∫àÕ¬„π‡¥Á°∑’ËÕ“¬ÿπâÕ¬°«à“†3†ªï “‡Àµÿ¬—߉¡à∑√“∫·πà
πÕπ °“√«‘π‘®©—¬Õ“»—¬Õ“°“√∑“ߧ≈‘π‘°‚¥¬¡’ criteria „π
°“√«‘π‘®©—¬ ¥—ßπ’È
(1) ‰¢â Ÿß ¡“°°«à“ 5 «—π
(2) ¡’º◊Ëπ´÷ËßÕ“®æ∫‡ªìπ†maculopapular
rash, urticaria, scarlatiniform, erythema multiformelike ·µà‰¡àæ∫ vesicobullous
(3) µ“·¥ß∑—Èß 2 ¢â“ß ‚¥¬‰¡à¡’¢’ȵ“
(4) °“√‡ª≈’ˬπ·ª≈ß∑’Ë√‘¡Ω望°†‚¥¬ª“°
·¥ß ·Àâß ·µ° (dryness, redness, fissuring) ·≈–≈‘Èπ·¥ß
§≈⓬ strawberry
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
41
µ“√“ß∑’Ë 3 °“√«‘π‘®©—¬·¬°‚√§ SSSS, Kawasaki, scarlet fever
Age
Fever
Rash
Desquamation
SSSS
< 5 yrs
+/+++
Erythroderma
End of 1st wk
Kawasaki
< 5 yrs
+++
Polymorphous
2nd wk
Location of desquamation
Lymph nodes
Leukocytosis, elevated ESR
Strawberry tongue
Conjunctivitis
Change of extremities
Generalised
++
-
Tip of fingers
Unilateral (cervical)
++
+
+
+
(5) °“√‡ª≈’ˬπ·ª≈ß∑’Ë¡◊Õ·≈–‡∑â“ Õ“®æ∫
º◊Ëπ·¥ß„π√–¬–·√° µàÕ¡“ —ª¥“Àå∑’Ë 2 ¢Õ߉¢â º◊Ëπ≈Õ°∑’Ë
ª≈“¬π‘È«¡◊Õ π‘È«‡∑â“ ´÷Ë߇ªìπ≈—°…≥–‡©æ“–¢Õß‚√§
(6) µàÕ¡πÈ”‡À≈◊Õß‚µ à«π„À≠à‡ªìπµàÕ¡πÈ”
‡À≈◊Õߢâ“ß§Õ ·≈–¡’¢π“¥¡“°°«à“ 1.5 ´¡.
°“√«‘π®‘ ©—¬ ºŸªâ «É ¬µâÕß¡’‰¢â ߟ √à«¡°—∫Õ“°“√
∑“ߧ≈‘π‘°Õ’° 4 „π 5 ¢âÕ ·≈–µâÕß·¬°‚√§Õ◊Ëπ Ê ‰¥â ‡π◊ËÕß
®“°¬—߉¡à¡’º≈∑“ßÀâÕߪؑ∫—µ‘°“√∑’˙૬„π°“√«‘π‘®©—¬∑’Ë·πà
πÕπ º≈∑“ßÀâÕߪؑ∫—µ‘°“√∑’˙૬·¬° §◊Õ CBC æ∫ leukocytosis, ESR Ÿß „π —ª¥“Àå∑’Ë 2 æ∫‡°≈Á¥‡≈◊Õ¥ Ÿß ´÷Ëß
‡ªìπ≈—°…≥–‡©æ“–‚√§
Õ“°“√Õ◊Ëπ Ê ∑’Ëæ∫‰¥â„π Kawasaki disease
䴉ᡈ hydrops of gall bladder, sterile pyuria, aseptic
meningitis, hepatitis, arthralgia œ≈œ
°“√«‘π‘®©—¬·¬°‚√§ µâÕß·¬°®“°º◊Ëπ®“°
°“√µ‘¥‡™◊ÕÈ ‰«√— ·∫§∑’‡√’¬ ·≈–º◊πË ·æ⬓ (Stevens-Johnson
syndrome)
°“√·¬° SSSS, Kawasaki, scarlet fever
(µ“√“ß∑’Ë 3)
°“√·¬° Kawasaki disease ·≈– StevensJohnson syndrome (µ“√“ß∑’Ë 4)
ªï∑’Ë 10 ©∫—∫∑’Ë 1
Scarlet fever
School age
+++
Scarlatiniform
1st wk (Staphylococci),
2st wk (Streptococci)
Generalised, palms & soles
Bilateral (cervical)
++
+
-
°“√√—°…“ „π√“¬∑’Ë ß —¬«à“‡ªìπ Kawasaki
syndrome†§«√ àßµàÕºŸâªÉ«¬‰ªæ∫°ÿ¡“√·æ∑¬å‡æ◊ËÕ„Àâ°“√
«‘π‘®©—¬∑’Ë·πàπÕπ ‡æ√“–‚√§π’Èæ∫§«“¡º‘¥ª°µ‘¢Õß√–∫∫
À—«„®·≈–À≈Õ¥‡≈◊Õ¥ Ÿß∂÷ß√âÕ¬≈–†10-30 ‚¥¬‡©æ“–æ∫
coronary dilatation ·≈– aneurysm ´÷Ë߇°‘¥„π√–¬–‡«≈“
1-3†‡¥◊ÕπÀ≈—ß¡’‰¢â ∂Ⓣ¡à√—°…“Õ“®®–¡’‚√§·∑√°´âÕπ‰¥â
ªí®®ÿ∫—π°“√„À⬓ gamma globulin ¢π“¥ Ÿß 2 °√—¡/°°.
§√—È߇¥’¬«∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ¿“¬„π 7 «—πÀ≈—ß¡’‰¢â ‰¢â®–≈¥
≈ßÕ¬à“߇√Á«À≈—߉¥â√—∫ gamma globulin √à«¡°—∫°“√„À⬓
·Õ ‰æ√‘π√—∫ª√–∑“π¢π“¥ 30-50 ¡°./°°./«—π „π√–¬–
·√°·≈–≈¥¢π“¥≈߇À≈◊Õ 3-5 ¡°./°°./«—π ‡¡◊ËÕ‰¢â≈¥≈ß
“¡“√∂ªÑÕß°—π‚√§·∑√°´âÕπ∑“ßÀ—«„®‰¥â
Atypical Kawasaki disease æ∫„π‡¥Á°
Õ“¬ÿπâÕ¬°«à“†6†‡¥◊Õπ ‚¥¬°“√«‘π‘®©—¬‰¡à®”‡ªìπµâÕߧ√∫
criteria ·µàµ√«®æ∫§«“¡º‘¥ª°µ‘¢Õß coronary artery
º‘ « À π— ß
·π«∑“ß°“√·¬°‰¢âÕÕ°º◊Ëπ„π‡¥Á°
ª√–«—µ‘ §«√´—°ª√–«—µ‘µàÕ‰ªπ’È
- Õ“°“√π”°àÕπ¡’º◊Ë𠇙àπ ‰¢â ‰Õ πÈ”¡Ÿ°
- §«“¡ —¡æ—π∏å√–À«à“ߺ◊Ëπ·≈–‰¢â
- Õ“°“√Õ◊Ëπ Ê ∑’Ëæ∫√à«¡¥â«¬ ‡™à𠇮Á∫§Õ ª«¥
‡¡…“¬π 2548
REVIEW ARTICLE
42
µ“√“ß∑’Ë 4 °“√·¬° Kawasaki disease ·≈– Stevens-Johnson syndrome
Kawasaki Disease
Stevens-Johnson Syndrome
Age of onset < 5 years
> 5 days high fever
Fever
Eyes
Injected conjunctiva, no exudate
Extremities
Induration of hands & feet, desquamation of tip of fingers
Oral change Erythema, fissuring, crusting of lips strawberry tongue
Polymorphous except vesicobullous
Unilateral cervical > 1.5 cm in diameter
Any age
Abrupt > 40° c with prodrome
Injected conjunctiva with exudate
No change of extremities
Swelling with hemorrhagic crusts ulcer
at buccal mucosa
EM, vesicobullous
Generalised cervical lymphadenopathy
∑âÕß Õ“‡®’¬π §—π œ≈œ
- ª√–«—µ‘ —¡º— ‚√§‰¢âÕÕ°º◊Ë𠇙àπ —¡º— °—∫
ºŸâªÉ«¬∑’ˇªìπÀ—¥
- ª√–«—µ‘‰¥â√—∫«—§´’π¡“°àÕ𠇙à𠉥â√—∫«—§´’π
À—¥ ∑”„À⧑¥∂÷ß‚√§À—¥πâÕ¬≈ß
- ª√–«—µ‘°“√‰¥â√—∫¬“Õ¬à“ß≈–‡Õ’¬¥„π™à«ß†3
—ª¥“Àå°àÕπ¡’º◊Ëπ
°“√µ√«®√à“ß°“¬
- Vital signs ‚¥¬‡©æ“–‰¢â ®–™à«¬·¬°‚√§
䴉
- °“√°√–®“¬¢Õߺ◊Ëπ ™π‘¥¢Õߺ◊Ëπ µ≈Õ¥®π
‡¬◊ËÕ∫ÿ¿“¬„πº◊Ëπ À√◊Õ√Õ¬‚√§„𪓰
- °“√µ√«®√à“ß°“¬√–∫∫Õ◊πË Ê Õ¬à“ß≈–‡Õ’¬¥ ‡™àπ
µàÕ¡πÈ”‡À≈◊Õß √–∫∫ª√– “∑ √–∫∫∑“߇¥‘πÀ“¬„® À—«„®
µ—∫ ¡â“¡ œ≈œ
°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√
- Complete blood count (CBC) ™à«¬·¬°
°“√µ‘¥‡™◊ÈÕ‰«√— ®“°°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬
- Erythrocyte sedimentation rate (ESR)
∂â“¡’§à“ Ÿßπ÷°∂÷ß°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬,†Kawasaki†disease
‡ªìπµâπ
- °“√‡æ“–‡™◊ÈÕ·∫§∑’‡√’¬®“°‡≈◊Õ¥À√◊Õº‘«Àπ—ß
„π√“¬ ß —¬ staphylococcal scalded skin syndrome,
meningococcemia ‡ªìπµâπ
- °“√µ√«®∑“ßÀâÕߪƑ∫—µ‘°“√Õ◊Ëπ Ê ·≈â«·µà
“‡Àµÿ ‡™àπ °“√‡®“–‡≈◊Õ¥ viral study „π√“¬ ß —¬À—¥
‡¬Õ√¡—π °“√‡®“–‡≈◊Õ¥ ANA profile „π√“¬ ß —¬ systemic
lupus erythematosus œ≈œ
®“°°“√»÷°…“¢Õß Drago F ·≈–§≥–19 ‡æ◊ËÕÀ“§«“¡
—¡æ—π∏å¢Õߺ◊Ëπ™π‘¥ atypical exanthem °—∫ “‡Àµÿ¢Õߺ◊Ëπ
‚¥¬»÷°…“ºŸâªÉ«¬πÕ° 112 √“¬ ‡ªìπºŸâ„À≠à 78 √“¬·≈–
‡¥Á°Õ’° 34 √“¬ ´÷Ëß¡’º◊Ëπ·∫∫ nonspecific maculopapular
rash º≈°“√»÷°…“·∫àߺ◊Ëπ„πºŸâªÉ«¬‡ªìπ 7 ™π‘¥ ‰¥â·°à maculopapular erythema 42 √“¬ macular erythema 32
√“¬, erythema with vesiculation 11 √“¬, papular
erythema 8 √“¬, maculopapular erythema with petechiae 7 √“¬, urticaria 7 √“¬ ·≈– erythema with
pustules 5 √“¬ ∑”°“√À“ “‡Àµÿ∑’Ë·πàπÕπ¢Õߺ◊Ëπ ‚¥¬°“√
∑” serology, PCR, throat swab culture „π√“¬ ß —¬
°“√µ‘¥‡™◊ÈÕ‰«√— ·≈–∑”°“√‡æ“–‡™◊ÈÕ„π√“¬ ß —¬°“√µ‘¥‡™◊ÈÕ
·∫§∑’‡√’¬
®“°°“√»÷°…“π’È æ∫ “‡Àµÿ¢Õߺ◊Ëπ 76 √“¬ (√âÕ¬≈–
68) ´÷Ë߇°‘¥®“°‡™◊ÈÕ‰«√— 32 √“¬ º◊Ëπ·æ⬓ 25 √“¬ °“√µ‘¥
‡™◊ÈÕ·∫§∑’‡√’¬ 16 √“¬ ·≈–®“° parasite 3 √“¬ æ∫«à“™π‘¥
Skin
Lymph node
ªï∑’Ë 10 ©∫—∫∑’Ë 1
º‘ « À π— ß
‡¡…“¬π 2548
REVIEW ARTICLE
¢Õߺ◊Ëπ·≈–ª√–«—µ‘ “¡“√∂™à«¬„π°“√«‘π‘®©—¬‰¥â ‚¥¬∂â“æ∫
º◊Ëπ erythema √à«¡°—∫ vesicle ®–‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ‰«√— ·µà∂⓺◊Ëπ‡ªìπ erythema ·≈– papule √à«¡°—∫Õ“°“√§—π®–
‡°‘¥®“° “‡Àµÿ®“°°“√·æ⬓ √ÿª®“°°“√»÷°…“π’Èæ∫«à“™π‘¥
¢Õߺ◊Ëπ√à«¡°—∫ª√–«—µ‘ “¡“√∂„Àâ°“√«‘π‘®©—¬º◊Ëπ‰¥â∂÷ß√âÕ¬≈–
43
70 ¢ÕߺŸâªÉ«¬
√ÿª‰¢â·≈–º◊Ëπ„π‡¥Á°Õ“®‡°‘¥®“°À≈“¬ “‡Àµÿ °“√´—°
ª√–«—µ·‘ ≈–°“√µ√«®√à“ß°“¬Õ¬à“ß≈–‡Õ’¬¥®– “¡“√∂«‘π®‘ ©—¬
‚√§‰¥â à«πº≈∑“ßÀâÕߪؑ∫µ— °‘ “√‡ªìπ‡§√◊ÕË ß™à«¬„π°“√«‘π®‘ ©—¬∑’Ë·πàπÕπ
‡Õ° “√Õâ“ßÕ‘ß ■
1. Schlossberg D. Fever and rash. Infect Dis Clin North Am 1996;10:101-10.
2. Frieden IJ, Resnick SD. Childhood exanthema: old and new. Pediatr Clin North Am 1991;38:859-87.
3. Cherry JD. Contemporary infectious exanthems. Clin Infect Dis 1993;16:199-205.
4. Hogan PA. Viral exanthems in childhood. Australas J Dermatol 1996;37:s14-6.
5. Mancini AJ. Exanthems in childhood: an update. Pediatr Ann 1998;27:163-70.
6. Duke T, Mgone CS. Measles: not just another viral exanthem. Lancet 2003;361:763-73.
7. Biaslecki C, Feder HMJr, Grant-Kels JM. The six classic childhood exanthems: a review and update. J Am Acad
Dermatol 1989;21:891-903.
8. Resnick SD. New aspects of exanthematous diseases of childhood. Dermatol Clin 1997;15:257-66.
9. Cohen JI. Epstein-Barr viral infection. N Eng J Med 2000;343:481-92.
10. Stalkup JR, Chilukuri S. Enterovirus infections: a review of clinical presentation, diagnosis and treatment. Dermatol
Clin 2002;20:217-23.
11. Nelson JS, Stone MS. Update on selected viral exanthems. Curr Opin Pediatr 2000;12:359-64.
12. Chuh AA. Diagnostic criteria for Gianotti-Crosti syndrome: a prospective case-control study for validity assessment.
Cutis 2001;68:207-13.
13. Oumeish I, Oumeish OY, Bataineh O. Acute bacterial skin infections in children. Clin Dermatol 2000;18:667-78.
14. Darmstadt GL, Galen WK, Fisher G. Bacteria infection. In: Schachner LA, Hansen RC. Pediatric dermatology. 3rd
ed. Edinburg: Mosby; 2003. p. 989-1057.
15. Cherry JD, Hurwitz ES, Welliver RC. Mycoplasma pneumoniae infections and exanthems. J Pediatr 1975;87:36973.
16. Shin HT, Chang MW. Drug eruptions in children. Curr Probl Pediatr 2001;31:207-34.
17. DeSilva TN, Kress DW. Management of collagen vascular diseases in childhood. Dermatol Clin 1998;16:579-92.
18. Gedalia A. Kawasaki disease: an update. Curr Rheumatol Rep 2002;4:25-9.
19. Drago F, Rampini E, Rebora A. Atypical exanthems: morphology and laboratory investigations may lead to an
aetiological diagnosis in about 70% of cases. Br J Dermatol 2002;147:255-60.
■
ªï∑’Ë 10 ©∫—∫∑’Ë 1
º‘ « À π— ß
‡¡…“¬π 2548