MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE
V. N. Karazin Kharkiv National University
DIFFERENTIAL DIAGNOSIS
OF INFECTIOUS DISEASES ACCOMPANIED BY EXANTHEMA
METHODICAL RECOMMENDATIONS
for students 5th and 6th courses of medical faculty
Kharkiv – 2020
1
УДК 616.9:616.15
LD
Reviewers:
L. I. Rak – head of the department of pediatrics and rehabilitation State
Institution "Institute for the protection of the health of children and adolescents
National academy of medical sciences of Ukraine", senior researcher, doctor of
medicine;
Z. V. Eloeva – head of department of pediatrics of Kharkiv medical academy
of postgraduate education, doctor of medicine.
Approved to the print by the decision of Scientific Council of V. N. Karazin
Kharkiv National University
(protocol №
from
)
LD Differential diagnosis of infectious diseases accompanied by exanthema:
methodical recommendations for students 5th and 6th courses of medical faculty /
compilers: O. O. Rzhevska, T. M. Kvaratskheliya. – Kharkiv : V. N. Karazin
Kharkiv National University, 2020. – 46 p.
© V. N. Karazin Kharkiv National University, 2020
© O. O. Rzhevska, T. M. Kvaratskheliya, comp., 2020
© I. M. Donchik, design of cover, 2020
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Contents
Introduction ..............................................................................................................4
Abbreviations ...........................................................................................................5
Definition and morphological types of rashes...........................................................6
Measles......................................................................................................................8
Rubella.....................................................................................................................13
Herpesviral infections, chickenpox……………………………………………….16
Shingles…………………………………………………………………………...21
Scarlet fever ............................................................................................................23
Pseudotuberculosis………………………………………………………………..27
Infectious erythema……………………………………………………………….30
Sudden exanthema………………………………………………………………...32
Enterovirus infection……………………………………………………………...33
Differential diagnosis of infectious diseases with exanthemas…………………...35
Question of self-control ..........................................................................................38
References...............................................................................................................44
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INTRODUCTION
Infectious exanthema is an important problem of infectology, which is
associated with their prevalence, clinical and etiological polymorphism and
difficulties in diagnosis, especially at the prehospital stage. Now the attention of
the whole world is riveted to measles as a big socio-economic problem, as the
periodic incidence continues to grow. Although measles immunization has been
going on for nearly 40 years, more than 20 million cases of measles are reported
worldwide every year.
Since the incidence of measles is regulated by vaccination, an increase in the
number of these diseases is primarily associated with a low level of vaccination.
The relevance of this problem also lies in the fact that the diagnosis of
infectious exanthema is mainly established on the basis of clinical symptoms and
only in some cases is confirmed by laboratory studies. Rubella and measles often
occur with a false diagnosis of atopic dermatitis.
A rash on the skin is of great diagnostic value in many infectious diseases
(scarlet fever, chicken pox, measles), since it is one of the main clinical symptoms
in making a diagnosis. Each of these diseases has its own characteristic symptoms.
Scarlet fever - toxicosis and tonsillitis, rubella - lymphadenopathy syndrome,
measles - catarrhal symptoms and Filatov-Koplik spots, but a common unifying
factor is a rash, in the absence of which a clinical diagnosis cannot be established.
The rash in each case reflects the nature of inflammation: with scarlet fever it is a
toxic rash, with measles it is a productive inflammation, the manifestation of which
is a maculopapular rash. Therefore, knowledge of the characteristics of the course
of infectious diseases accompanied by exanthema in children is very important and
relevant.
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ABBREVIATIONS
CBC
complite blood count
ELISA
enzyme-linked immunosorbent assay
PCR
polymerase chain reaction
SMR
cerebrospinal fluid
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DEFINITION AND MORPHOLOGICAL TYPES OF RASH
A rash is a focal reaction of the skin to the action of pathogens and their
metabolic products (toxins, antigens). Exanthemes are divided into 2 large groups:
infectious and non-infectious (dermatoses, urticaria, epidermolysis, systemic
vasculitis).
Exanthemas are skin rashes caused by an infectious disease.
Enanthemas are corresponding changes in the mucous membranes.
Erythema is a diffuse or localized reddening of the skin.
When we have a child with a rash, the following questions contribute to the
diagnosis, which must be answered in each case:
- the nature of the rash (spotted, roseolous, hemorrhagic)
- color of the rash;
- localization of rashes (where it is located)
- the time of the appearance of the rash (it takes time to form a productive
inflammation, so roseola does not appear immediately, but after 7 days, and the
rash with scarlet fever immediately)
- the number of rash elements (single, abundant, tendency to merge).
The rash can be very diverse and vary in the nature of the morphological
elements: a spot, papule, vesicle, bulla, hemorrhage, nodule are the main elements
of the rash.
A spot from 5 to 20 mm, irregular in shape, does not protrude above the skin
level, is formed as a result of the expansion of the vessels of the papillary dermis,
disappears with pressure.
Roseola - spot up to 5 mm.
small spotted rash - spot size from 5 to 10 mm (with rubella).
large spotted rash - spot size from 10 to 20 mm (with measles).
Erythema - spot size more than 20 mm.
Hemorrhages - spots of various sizes (petechiae, purpura, ecchymosis), do
not disappear with pressure, occur when the vascular wall is damaged or its
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permeability increases. The color of hemorrhage can be different: red, purple,
violet-red (with meningococcemia). Petechiae - small hemorrhages under the
epidermis. Ecchymoses are large areas of hemorrhage.
Papule - an element of a rash, protrudes above the skin level, when pressed,
it does not disappear. It is formed as a result of vasodilation and cell infiltration in
the upper layers of the dermis or with the growth of the epidermis. After the
disappearance of the papules, pigmentation remains.
A combination of rash may be observed:
- maculopapular (measles)
- roseolo-papular (rubella).
A tubercle is a type of papule that occurs as a result of the formation of an
inflammatory granuloma in the dermis with the subsequent appearance of an ulcer
or scar.
A nodule is a limited compaction of the skin, often protruding above its
surface (nodosum erythema).
Vesicle (bubble) - may be with serous or serous-purulent exudate. The
vesicle is formed as a result of balloon dystrophy of epidermal cells at the border
with the dermis. The contents of the vesicles shrink into a crust. Vesicles do not
leave scars on the skin. In case of accumulation of a large number of leukocytes in
the vesicle, it turns into an abscess - a pustule. Single-chamber vesicles are
characteristic of chickenpox, herpes.
Secondary elements of the rash include pigmentation, erosion, crusts, scars,
peeling.
In the early stages of the disease, for the differential diagnosis, the primary
elements of the exanthema rash are important, for retrospective diagnosis, the
secondary elements (peeling with scarlet fever). Other clinical manifestations have
a
diagnostic
value
in
exanthema:
conjunctivitis,
specific
enanthema,
lymphadenopathy.
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MEASLES
Measles is a highly contagious viral disease characterized by fever, catarrh
of
the
upper
respiratory
tract
and
conjunctivitis,
specific
enanthema,
maculopapular rash.
Etiology: measles is caused by an RNA virus from the family of
Paramyxoviridae, genus Morbillivirus. Has a cytopathogenic effect. Measles virus
has a defective protein M, therefore, it can stay and persist in the body for life,
causing a slow infection - sclerosing panencephalitis. The causative agent can
remain active for at least 34 hours at room temperature. During the prodromal
period (catarrhal stage) and for a short time after the rash appears, the virus appears
in the secretions from the nasopharynx, blood and urine.
Epidemiology: Measles is endemic to most countries in the world. Measles
is highly contagious (approximately 90% susceptibility). An infected person
becomes infectious on the 9-10th day after infection (the beginning of the
prodromal period), in some cases already on the 7th day. Caution regarding
isolation, especially in hospitals, should be observed from the 7th day after
infection to 5 days after the rash. Mechanism of transmission is airborne.
Classification of measles (V. Uchaykin, 2001):
By type:
Typical measles: typical in severity: mild; moderate; severe (without
hemorrhagic syndrome, with hemorrhagic syndrome);
Atypical forms of measles: mitigated (in vaccinated); abortive; worn out;
asymptomatic; in persons with immunodeficiencies; hemorrhagic; in case of
combination with other infections; in pregnant women.
With the course: smooth (uncomplicated); not smooth (complicated).
Complications:
By etiology:
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- primary (due to measles virus) - laryngotracheitis (croup), bronchitis,
encephalitis, giant cell pneumonia and diarrhea are common in infants;
- secondary (bacterial) - otitis media, pneumonia, gingivostomatotitis,
pyelonephritis, diarrhea, dermatitis .
By time of occurrence: early (in the prodromal and rash period); late (in the
pigmentation period).
Localization: respiratory system (laryngitis, laryngotracheobronchitis,
pneumonia); digestive system (enterocolitis, colitis), nervous system (encephalitis,
serous meningitis, encephalomyelitis), eyes (keratitis), ear (otitis media), skin
(staphilo- or streptoderma), urinary system (pyelonephritis).
Clinical symptoms of measles. The course of measles consists of 4 periods.
The first incubation period: 10-12 days (9-17 days). A patient receiving
immunoglobulin may have it for longer (up to 21 days).
The next catarrhal period lasts 3-5 days and is manifested by fever, rhinitis,
conjunctivitis, sore throat and dry cough. There are classic three "Сs" (Cough,
Corryza, Conjunctivitis). Koplik spots are pathognomonic for measles (gray-white
papules on the mucous membrane of the cheek, usually as small as sand, with a
slight red areola). It appears on the mucous membrane of the cheeks opposite the
molars, where they resemble coarse grains of salt on the surface of the inflamed
membrane. Usually they disappear on the second day of exanthema. Symptom
Petene - hemorrhagic preenanthema on the mucous membrane of the oral cavity.
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The period of rashes. The leading
symptom of measles is a maculopapular
rash, has tendency to merge, profuse,
bright.
The
rash appears
on
the
unchanged skin, on the 4-5th day from
the onset of the disease together with
the second wave of fever. The rash
appears on the 14th day from infection,
it helps to establish where and when the
patient became infected. The measles
rash is characterized by the stages of rash: day 1 - behind the ears, on the face,
neck, on the 2nd - the trunk, arms, on the 3rd - the hips, lower legs, feet, and on the
face the rash begins to turn pale.
Pigmentation period. After 3-4 days, pigmentation remains at the site of the
rash. The main reason for pigmentation is the deposition of hemosiderin as a result
of hemorrhagic effects on tissues.
The most common measles symptoms are:
1) high fever;
2) significant respiratory-catarrhal phenomena (three "Сs");
3) Koplik spots on the mucous membrane of the cheeks;
4) enanthema on the mucous membrane of the hard and soft palate;
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5) the phased appearance of a rash (face, neck, trunk, proximal and distal
parts of the arms and legs);
6) a maculopapular rash, which has tendency to merge, increases rapidly in
size.
Measles can also occur in two forms: modified and atypical measles.
Modified measles occurs in partially immune individuals: in previously vaccinated
individuals, in infants with maternal antibodies to IgG, and in patients receiving
immunoglobulin therapy. Clinical manifestations are milder and shorter than in a
typical infection. The incubation period lasts for 14-20 days. Koplik spots are rare.
The rash begins distally with minor facial damage. However, the disease is also
very contagious in these people. The diagnosis is established on the basis of
clinical manifestations with laboratory confirmation, if necessary.
Atypical measles is represented by a sharp increase in temperature,
accompanied by abdominal pain, myalgia, chest pain and cough, and vomiting.
Papular or papular-vesicular hemorrhagic rash on the extremities begins in 2 to 5
days and spreads centrally. In these cases, differential diagnosis with
meningococcemia is necessary.
Diagnosis: usually only clinically.
Laboratory
tests:
СВС:
leukopenia,
lymphocytosis,
eosinophilia,
rarely
thrombocytopenia.
Serology: Measles IgM can usually be detected after the first 3 days of exanthema,
a significant increase in measles IgG titer in paired blood serum. Detection of
measles antigen in nasopharyngeal aspirate by immunofluorescence. Identification
of measles RNA by PCR. Isolation of measles virus from clinical samples of urine,
blood, or nasopharynx. A histological evaluation of skin lesions or respiratory
secretions can detect giant cell syncytial keratinocytes.
Diagnostic example:
• Measles, typical form, period of exanthema, mild severity, uncomplicated.
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• Measles, typical form, period of pigmentation, severe (with hemorrhagic
syndrome), complicated by left-sided polysegmental (S3 - S6) pneumonia,
respiratory failure of 2 degrees.
Differential diagnosis: other maculopapular exanthema such as rubella,
roseola, enterovirus infection, infectious mononucleosis, B-19 parvovirus
infection, scarlet fever, rickettsial diseases, serum sickness, Kawasaki disease,
toxic shock syndrome and drug intoxication.
Complications: the most common complications are otitis media,
pneumonia,
laryngotracheobronchitis
(croup)
and
diarrhea.
Transient
immunosuppression lasts approximately 6 weeks. Hepatitis, thrombocytopenia,
and encephalitis are less common. Acute post-infectious encephalitis (1/1000
patients) and subacute sclerosing panencephalitis (SSPE) (1/100 000 patients). One
of the potential dangers is the exacerbation of latent tuberculosis.
Symptomatic (supportive) treatment: antipyretic drugs, bed rest and
adequate fluid intake. Vitamin A inside. Suppressors for coughing or mucolytics, if
indicated. Oral care (rinsing with antiseptic fluids) and conjunctiva care. There is
no specific antiviral therapy. In the case of a bacterial complication, antibiotic
therapy should be used. In the case of croup and / or severe episodes,
corticosteroids (1-2 mg / kg for 2–3 days).
Prevention: specific: active immunization (measles vaccine) and passive
immunization (serum gamma globulin). In Ukraine, specific active immunization
with the measles, mumps, and rubella vaccine is carried out at the age of 12
months. Revaccination is carried out after 6 years.
Nonspecific: isolation of a sick person until the 5th day of exanthema (if
complicated by pneumonia, encephalitis - until the 10th day), isolation of the
contact person from 8 to 17 days (in the case of specific immunoglobulin
prophylaxis - up to 21 days).
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RUBELLA
Rubella is a viral infection that has an acquired form (with an airborne
droplet transmission mechanism, mild clinical signs and benign completion) and
congenital (with a transplacental transmission mechanism and the development of
severe fetal malformations). Rubella is the most common infectious disease among
infections that can be controlled with specific prophylaxis. Of particular relevance
is congenital rubella, which is associated with a specific gravity of congenital
malformations, which is why rubella has acquired social and medical significance.
Etiology Rubivirus containing RNA in the family Togaviridae.
Epidemiology: susceptibility is common, especially high in children 2–9
years old. Infectious patients 1 week before the rash appears and within a week
after the rashes begin to disappear. Transmission: airborne and transplacental
Classification of acquired rubella (V.F. Uchaykin, 2001):
By type: typical forms; atypical forms (obliterated, asymptomatic).
By severity: light; moderate; heavy;
With the course: smooth (uncomplicated) uneven (complicated).
Specific complications: meningitis, encephalitis, synovitis.
The clinical picture: The incubation period is 2-3 weeks (18-23 days).
The main clinical symptoms of rubella are rash and lymphadenopathy.
The first and main symptom of rubella is lymphadenopathy, which is characterized
by a moderate increase in lymph nodes, often posterior and occipital. The nodes
are soft, slightly painful on palpation, 1-2 cm in size. Enlarged lymph nodes can be
found 5-10 days before the rash appears and within 1-2 weeks after its
disappearance.
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The leading symptom of rubella is a
rash. A rash on the skin appears
simultaneously throughout the body.
The rash is small-papular or maculopapular, has no tendency to merge. The
highest concentration of rash is on the
extensor surface of the limbs, back,
buttocks. The rash disappears quickly in
1-3 days without the formation of
pigmentation, sometimes accompanied
by mild itching.
In 20-30% of cases, rubella can develop without rashes.
Catarrhal manifestations from the mucous membranes of the upper
respiratory tract are poorly expressed, are inconsistent, intoxication is insignificant,
body temperature is low-grade or normal, but in some patients it can reach up to
38ºС. Until the rash disappears, the body temperature also normalizes.
Acquired rubella is benign, but older children and adults may experience
complications - encephalitis, thrombocytopenic purpura, arthritis. Since rubella can
resemble many other infectious diseases in the clinical course, laboratory
confirmation of the diagnosis must be carried out. The clinical diagnosis of rubella
is considered unlawful.
The most common clinical symptoms of rubella are:
1. An increase in the occipital and posterior cervical lymph nodes.
Lymphadenitis is the first symptom of rubella.
2. The rash is small-papulose, pale pink on a normal skin background,
appears on the 1-2 days of illness.
3. Localization on the limbs, hips, abdomen.
4. Lack of pigmentation.
5. The body temperature is normal or low-grade.
6. Lack of intoxication, respiratory catarrhal syndrome, tonsillitis.
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7. There is no lymphocytosis in the peripheral blood.
The most serious course is congenital rubella syndrome, which is
classically represented by a triad: deafness, cataract and heart disease. Common
congenital heart diseases include patent duct arteriosis (PDA), aortic valve defect,
aortic stenosis (AS), aortic coarctation (CoA), interventricular septal defect (VSD),
pulmonary artery stenosis (PS), atrial septic defect (ASD), transposition of large
arteries (TGA).
Eye lesions, other than cataracts, include microphthalmia, retinopathy,
corneal opacity, and glaucoma.
In addition, most children have pathognomonic petechial rashes, low birth
weight, microcephaly, and palate. Myocarditis, hepatitis, meningoencephalitis,
interstitial pneumonia are also commonly detected.
Diagnosis: clinically. Laboratory studies: СВС nonspecific (leukopenia,
lymphocytosis, plasma cells, normal ESR). Laboratory data for congenital rubella:
thrombocytopenia, hemolytic anemia, hypogammaglobulinemia.
Serological: inhibition of hemagglutination, ELISA, latex agglutination or
ELISA. Detection of specific rubella IgM indicates a recent postpartum infection.
Serous IgG conversion or a 4-fold increase in blood serum titers in the acute and
convalescence state indicates infection. Virological: PCR - virus isolation from
swabs of secretions, urine, blood, saliva and CMP. Express methods - phase
contrast microscopy, microagglutination reaction.
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Diagnosis example: Rubella, typical form, exanthema period, mild severity,
complicated.
Differential diagnosis: other maculopapular exanthema, such as measles,
roseola, B-19 parvovirus infection, scarlet fever, infectious mononucleosis and
drug intoxication.
Complications: lack of acquired form and disability with congenital rubella.
The treatment is symptomatic. No specific antiviral therapy.
Prevention: specific - active immunization. In Ukraine, vaccination over 12
months with a vaccine against RMM (together with measles and mumps
vaccination), revaccination after 6 years, if not done earlier - after 15 years with a
monovaccine (girls). If the titers of antibodies to anti-rubella in young women are
negative, immunization against rubella should be carried out. In adolescents,
pregnancy should be excluded with a possible adverse effect of the vaccine on the
fetus. Nonspecific prophylaxis: isolation of patients after 4 days from the start.
HERPESVIRUS INFECTION
Herpes infection is caused by the herpes virus family (DNA-containing
virus) HSV types 1 and 2, varicella-Zoster virus (HHV-3), EBV (Epstein Barr
virus, HHV-4), CMV (cytomegalovirus, HHV-5), HHV-6 , HHV-7, 8 (human
herpes virus), which tend to persist in the human body throughout his life and the
ability to cause various clinical forms in case of development of immune
deficiency.
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CHICKENPOX
Chickenpox is an acute viral disease caused by a virus from the herpes virus
family, characterized by fever and a vesicular rash with clear contents.
Etiology: DNA-containing virus is a type 3 herpes virus. Primary infection
of VZV causes chickenpox. The virus causes a latent infection in the dorsal root
ganglia; its reactivation causes herpes zoster (herpes zoster).
Epidemiology: annual chickenpox epidemics occur in winter and spring.
The transmission coefficient is 80-90%. Chicken pox is contagious 24-48 hours
before the rash, the entire period of the rash and another 5 days after the last
element of the rash appears. Transmission: occurs through respiratory secretion
and fluid produced by skin lesions, airborne or through direct contact.
Clinical classification (V.F.Uchaykin, 2001):
By type: typical forms;
atypical forms:
- Rudimentary: in children with passive immunity who received
immunoglobulin or plasma injection in the latent period (not numerous rashes,
since papules with several vesicles appear, body temperature is normal).
- Bullous: along with typical rashes, large vesicles appear up to 2-3 cm with
cloudy contents, after which erosion and pigmentation develop.
- Hemorrhagic: develops in children with weakened immunity, the contents
of the vesicles becomes hemorrhagic, the crusts turn black. There are other signs of
hemorrhagic syndrome (petechiae, ecchymosis, nosebleeds, hemorrhages in the
internal organs).
- Gangrenous: develops in children with impaired immunity in case of poor
care. The contents of the vesicles become hemorrhagic with infiltration around
them, the crusts are black, the ulcer is typical.
- Generalized (visceral) is characteristic of newborns and in the case of
immune deficiency.
By severity:
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- light form (few vesicular rashes on the skin, t 37.5-38 ° С)
- Moderate severity (a significant amount of vesicular rashes on the skin,
single on the mucous membranes of the oral cavity, t 38-39 ° C)
- severe (numerous rashes, hardening at the stage of vesicles on the skin and
mucous membranes, t up to 40 ° C and above)
- generalized (visceral) (neurotoxicosis with convulsive syndrome and
meningoencephalic reactions, hyperthermia, multiple rashes in the form of
vesicles quite often with hemorrhagic contents, damage to internal organs)
- rudimentary (skin rashes do not reach the stage of vesicles (only maculapapules), t ° normal)
By the course: (a) smooth, without complications; (b) complicated by
encephalitis, neuritis, polyradiculoneuritis; (c) complicated by a secondary
bacterial infection, such as lymphadenitis, pyoderma (staphilo- and streptoderma),
erisipeloid, phlegmon, abscess, sepsis.
Clinical manifestations. Incubation period: 11-21 (usually 14-17) days.
Prodromal symptoms are common: fever, malaise, anorexia, headache, and
sometimes mild abdominal pain 24-48 hours before the rash appears. Fever and
other systemic symptoms persist for the first 2-4 days after the rash.
For the period of rash with chickenpox, a vesicular rash is characteristic, the
contents of the vesicles are transparent. The rash appears on the 1-2 day of the
disease on the scalp, on the face, trunk and extremities. First, itchy erythematous
maculae (spots) appear, then the maculae turn into papules, and those turn into
vesicles filled with a clear liquid, which then burst and become crusty. Turbidity
of the transparent contents of the vesicles, as well as involution of lesions, begin
after 24-48 hours. While the initial lesions acquire a reverse development, new
elements form on the body, and then on the limbs. The simultaneous presence of
lesions at different stages of evolution is characteristic of chickenpox (false
polymorphism). The rash can also be in the oral cavity, on the conjunctiva of the
eyes, genitals. The appearance of new rashes is accompanied by an increase in
18
body temperature. Lesions can heal with the appearance of hypopigmentation and
scarring. The posterior cervical lymph nodes are usually enlarged.
The transferred disease does not give persistent immunity, therefore,
repeated cases of chickenpox can be hardened. The absence of rashes on the palms
and soles is important (differential diagnosis with enterovirus infection).
Diagnosis: clinical. Lab tests: usually not needed. СВС: leukopenia is typical
during the first 72 hours; then relative and absolute lymphocytosis. Tzanck smear can
detect multinucleated giant cells in vesicle. Immunofluorescence antibody (vesicle
fluid contains virus in the first days of illness).
Serology: IF assay, latex agglutination, complement fixation test.
19
Viral culture, PCR.
Example of diagnosis: chickenpox, typical form, moderate, complicated by
left otitis.
Differential diagnosis: impetigo, herpes simplex virus (HSV) infection,
insect bites, scabies and drug reactions.
Complications: Secondary bacterial infections of skin; otitis, pneumonia,
lymphadenitis, stomatitis, purulent conjunctivitis and keratitis, sepsis, osteomyelitis
usually due to group A Streptococcus or Staphylococcus aureus.
Neurological complications: encephalitis and meningoencephalitis, cerebellar ataxia,
transverse myelitis and Guillain–Barre syndrome.
Varicella hepatitis is relatively common and is usually subclinical.
Other
complications
include
arthritis,
glomerulonephritis,
myocarditis,
thrombocytopenia and purpura fulminans.
Higher risk of progressive disease with multiorgan involvement and hemorrhagic
varicella in immunocompromised children.
The congenital varicella syndrome is result of maternal infection in the
first trimester of pregnancy by VZV and associated with unusual cutaneous
defects, atrophy of an extremity, microcephaly, ocular defects, and damage to the
autonomic nervous system. Maternal varicella 5-10 days before delivery result in
mild chickenpox in newborn from the first days of his life. Maternal varicella 2
days before or 4 days after delivery may result in severe progressive varicella in
the newborn.
Treatment: usually symptomatic: antipyretic, antiseptics for skin lesions to
prevent secondary bacterial infection (1 % brilliant green, 1-2 % KMnO4); oral
antiseptic fluids after the food intake. Antihistamines 1st generation can relief itch.
Oral acyclovir is recommended for adolescents and young adults (high risk for
developing severe illness) for 5 days, ideally starting within 24 h of the development
of a varicella rash. Acyclovir IV is used for patients who have a severe or potentially
severe VZV infection, such as immunocompromised patients. The recommended
duration of ACV therapy is 7 days, or until no new lesions have appeared for 48
20
h. Therapy should be started within 24 h of onset, but up to 72 h after the appearance
of the skin lesions.
Prevention: Isolation ill person until the 5 day after the last vesicles has
appeared. Isolation contacts from 11 till 21 day after exposure.
Passive immunization: Varicella-zoster immune globulin (VZIG) is recommended
for immunocompromised children, pregnant women, and newborn infants exposed
to maternal varicella (not later than 72 hr after exposure).
Active immunization: varicella vaccine. The live, attenuated varicella vaccine, made
from the Oka strain, is the first human herpesvirus vaccine.
SHINGLES (HERPES ZOSTER)
Etiology: After the primary infection, VZV becomes latent in dorsal root
ganglia cells. Herpes zoster is caused by reactivation of the virus, at which time, the
virus travels back to the skin along the sensory nerve.
Epidemiology: it is uncommon in childhood, but more common in teens and
adults, incidence increases significantly in immunocompromised patients, because
reactivation is probably due to declining cell-mediated immunity.
Clinical manifestation: A prodrome of unusual skin sensations may evolve
into pain, burning and paresthesias, which precede the rash by two to three days. The
rash begins as painful or pruritic erythematous maculopapular eruption that rapidly
evolves to a vesicular rash.
The characteristic vesicular rash usually unilateral and affects one to three
dermatomes. The most common locations are the chest and the face. Drying of the
lesions with crust formation generally occurs in 7 to 10 days, and the lesions usually
resolve in 14 to 21 days.
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Diagnosis: clinical.
Differential diagnosis: chicken pox, streptococcus impetigo, erysipelas,
eczema, adenoviral keratoconjunctivitis.
Complications: Transverse myelitis with transient paralysis, postherpetic
neuralgia (rare). Secondary infection, meningo-encephalitis, pneumonitis, hepatitis,
myocarditis, pancreatitis, esophagitis, cystitis, granulomatous arteritis, conjunctivitis.
Treatment: Acyclovir. Local therapy: antiviral ointments and creams
locally (acyclovir, oxolin, tebrophen); antiseptic fluids (solution of diamond green,
methylen blue, peroxide of hydrogen); local anesthetics, novocain blockades;
NSAIDs (paracethamol 10-15 mg/kg or ibuprophen 10mg/kg); ultraviolet
irradiation.
Prevention: Isolation of patient up to 5 days since the last rashes appear,
hospitalization in case of severe and complicated course. Contact person younger
than 3 years, which have not Herpes Zoster before, are isolated from 11 till 21 day
since the contact, for the newborns 0.2 ml/kg normal immunoglobulin IM.
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SCARLET FEVER
Scarlet fever is an acute infectious disease caused by b-hemolytic group A
streptococcus, transmitted by airborne droplets, characterized by intoxication, skin
rashes, tonsillitis, regional lymphadenitis and strawberry tongue.
Etiology: b-hemolytic group A streptococcus (GABHS), which produces
one of three pyrogenic (erythrogenic) exotoxins.
Epidemiology: Children 2–9 years of age have a high susceptibility. The
source of infection is a person with GABHS infections. Transmission: airborne
droplets. Scarlet fever may be due to infection of wounds (i.e., surgical scarlet
fever), burns, or streptococcal skin infection.
Pathogenesis has three lines:
1) Toxic (toxic damage to the cardiovascular, endocrine systems, central
nervous system).
2) Septic - primary inflammation at the site of infection (tonsillitis,
secondary bacterial complication).
3) Allergic - sensitization with GABHS proteins (suppression of immunity
leads to allergic complications - nephritis, arthritis, myocarditis, rheumatism).
Classification (V.F. Uchaykin, 2001):
1. By form:
a) typical;
b) atypical: erased; extrapharyngeal (burns, wounds, after childbirth,
operations); with pointed symptoms (hypertoxic, hemorrhagic).
By severity: light; moderate; severe: toxic, septic, toxic-septic.
By duration: uncomplicated; complicated (relapses, complications).
Clinical manifestations: Incubation period: 1-7 (average 3) days.
The onset of the disease is acute, fever, headache, intoxication, sore throat,
flaming pharynx, acute tonsillitis syndrome (catarrhal, follicular, lacunar, necrotic
and fibrinous tonsillitis). The anterior cervical and submandibular lymph nodes are
23
sensitive and enlarged. The soft palate and ovulae may be swollen, reddened and
covered with petechiae.
In the early days of the disease, the back of the tongue is covered with a
white coating, on which the red and swollen papillae protrude. After 4-5 days, the
coating disappears, the tongue acquires a bright red color with swollen papillae
(that is, red strawberry tongue, raspberry tongue).
Rash. A typical rash appears within 12-48 hours. The rash is red,
pin-pointed or small-papular, appears in the first two days from the onset of the
disease, the background is hyperemic. In some people, the rash can be more easily
felt than seen, as the skin acquires the texture of goose or rough sandpaper
(“shagreen skin”). The rash appears first in the inguinal, groin and neck, but
becomes generalized within 24 hours. The forehead and cheeks appear rosy, and
the area around the mouth is pale (a pale nasolabial triangle is a symptom of
Filatov). The rash is most intense on skin folds and in places of pressure.
Localization of the rash: places of natural folds, lower back, lateral surfaces of the
trunk, proximal limbs and other flexion surfaces. Saturation of the rash is a
measure of the severity of scarlet fever. Positive Konchalovsky symptome ("pinch",
"tourniquet") is observed due to the appearance of petechiae due to fragility of
blood vessels and their increased permeability.
Scarlet fever mask according to Filatov is a continuous erythema,
streptococcosis of the skin and a pale nasolabial triangle (since it is innervated by
parasympathetic nerves). The rash disappears after 3-5 days without leaving
pigmentation.
At the end of the 1st at the beginning of the 2nd week, the period of
convalescence begins, a large-plate peeling appears, which begins with the tips of
the fingers and toes. Duration of peeling from 2 to 6 days.
24
The most typical clinical symptoms of scarlet fever:
1. intoxication syndrome with hyperthermia, lethargy, adynamia, vomiting.
2. Bright, clearly limited hyperemia of the oropharynx ("flaming pharynx").
3. Acute tonsillitis - from the catarrhal form to the lacunar and even necrotic.
4. “Strowberry tongue” - from the 2-3rd day of the disease, at first it is
densely coated with plaque, it is cleaned from the tip and edges and becomes bright
red with clearly expressed hypertrophied papillae.
5. The presence of a pin-pointed rash on a hyperemic skin background with
thickening in places of natural folds, a positive symptom of Pastia (hemorrhages in
places of natural folds), the absence of a rash on the nasolabial triangle (Filatov’s
upper triangle) and significant expressed in the inguinal region (Filatov’s lower
triangle).
2. Stable white dermographism, dry, hot to the touch skin.
3. Large-plate peeling of the skin, which appears from the end of the first
week of the disease and is most pronounced on the palms and soles.
25
Diagnosis: clinical and positive throat culture or rapid test of a pharyngeal swab
for group A Streptococci. Antistreptolysin-O titers or antideoxyribonuclease B titers
may also be used to indicate recent infection.
Laboratory tests: An increase in antistreptolysin O (ASO) titer occurs within the first
3–6 wk following infection. Anti-DNase (deoxyribonuclease) B provides the best
serologic test for streptococcal pyoderma; it begins to rise 6–8 wk after infection.
CBC: leukocytosis, elevations in the ESR and CRP are nonspecific and do not help to
establish a diagnosis.
Mandatory ECG, CBC and urinanalysis on the 10th day after the disease
began, and on 21th day for recognize possible late complications!
Diagnosis example:
• Scarlet fever, typical form, exanthema period, severe (toxic) degree,
complicated by right-sided peritonsillar abscess.
• Scarlet fever, typical form, recovery period, moderate, complicated by
myocarditis.
Differential diagnosis: tonsillitis may be seen in diphtheria, infectious
mononucleosis, adenovirus, and mycoplasma; rashes may be seen with measles,
rubella, roseola and pseudotuberculosis. Kawasaki disease, drug eruption, and
toxic shock syndrome must also be considered. Streptococcal pyoderma must be
differentiated from staphylococcal skin disease.
Complications: infectious (sinusitis, otitis media, mastoiditis, pyodermia,
necrotizing
tonsillitis,
retropharyngeal
or
parapharyngeal
abscess,
purulent
lymphadenitis, pneumonia, meningitis, osteomyelitis, or septic arthritis, sepsis); and
allergic (rheumatic fever, glomerulonephritis).
According the etiology, infectious complications are devoted into specific or
primary (caused by the same streptococcus); and secondary (caused by the other
bacteria).
They may be early (first week of the disease); and late (2nd - 3rd week).
Treatment: penicillin for 10 days. A single IM injection of a long-acting
benzathine penicillin G may be more effective for treatment or prevention of relapse
26
and is indicated for all noncompliant patients or those having nausea, vomiting, or
diarrhea. Erythromycin, clindamycin, or cefadroxil may be used for treating
streptococcal pharyngitis in patients who are allergic to penicillin.
In the severe case: cefalosporins of the 1st-2nd generation, klindamycin,
vancomycin intravenous for 10-14 days, fluid IV.
Prevention: nonspecific. Isolation of the patient on the 10 days, school
attendance after 22 day of the disease. Contact person (children before 8 years) must
be isolated for 7 days (period of incubation).
PSEUDOTUBERCULOSIS
Pseudotuberculosis is an acute infectious disease characterized by a
pronounced polymorphism of clinical symptoms with a predominance of toxicallergic syndrome, rashes, as with scarlet fever, and damage to the gastrointestinal
tract and liver, often has a relapsing course. Pseudotuberculosis infection is most
often perceived as pseudoapendicitis syndrome without diarrhea.
Etiology:
Yersinia
pseudotuberculosis,
gram-negative
bacillus,
Eprerobacteriaceae family.
Epidemiology: The source of infection is animals (rats, dogs, foxes, cats
and others). Transmission: аlimentary.
Seasonal morbidity in humans is parallel than in wild and domestic animals.
Classification of clinical forms (V.F.Uchaykin, 2001):
By type:
1) typical form: scarlet fever-like; abdominal; arthralgic; icteric (jaundice);
combined; septic.
2) atypical forms: catarrhal; erased; subclinical.
By severity: mild, moderate, severe.
27
Severity indicators: meningoencephalitic syndrome, hemorrhagic syndrome,
significant damage to the liver, abdominal, joint damage syndrome, signs of
generalization of the process.
By duration: smooth; uneven with exacerbations and relapses, uneven with
complications.
Clinical manifestations: The incubation period: 3-18 days.
Pseudotuberculosis has common features with scarlet fever: acute onset,
intoxication, strawberry tongue, pinpointed red rash (as with scarlet fever),
petechiae in the folds of the skin, positive symptoms of Pastia and Konchalovsky,
large plate desquamation, exudative inflammation in the peripheral blood. The
disease begins acutely with high body temperature, rhinopharyngitis.
However, there are some differences from scarlet fever. Pseudotuberculosis
is characterized by a polymorphism of complaints: fever, malaise, headache,
insomnia, anorexia, arthralgia, muscle pain, sore throat, nausea, abdominal pain,
dyspepsia. There is no angina, only pharyngitis is observed.
Rashes: maculopapular pinpointed red (as with scarlet fever), there may be
erythematosis or even erythema nodosum, however, the localization of the rash
differs from scarlet fever: it increases periorbitally (symptom of “glasses”), on the
neck (symptom of “hood”), on the arms (“symptom gloves”), legs (“socks”), in
folds of skin, in places of pressure (red dermographism), around joints. There is
hyperemia and swelling of the palms and soles. The rash usually lasts from 4 to 5
days, and then desquamation first on the face, other parts of the body and continues
on the palms and soles.
Catarrhal syndrome: cough, runny nose, pharyngitis and tonsillary erythema
without exudate, conjunctivitis. Bronchitis or pneumonia may develop.
The combination of exanthema with lymphadenitis (especially mesadenitis)
is important.
Abdominal syndrome: abdominal pain is diffuse or localized in the lower
right quadrant. Dyspepsia: nausea, vomiting, diarrhea. Ultrasound may show
typical mesenteric lymph nodes, a thickening of the terminal ileum and a lack of an
28
appendix.
Mesenteric
adenitis
should
be
suspected
in
children
with
incomprehensible fever and abdominal pain. Hepatomegaly, rarely - splenomegaly,
lymphadenopathy. Hepatitis with or without jaundice may develop.
Arthralgic syndrome: arthritis or arthralgia may develop.
Toxic myocarditis, toxic nephritis, pyelonephritis can be observed.
Diagnosis: clinical. Serologic tests have been described.
Laboratory tests: CBC: leucocytosis, neutrophilia with left shift, eosynophilia,
elevated ERS. Microbiological: Y. Pseudotuberculosis may be found in feces, urine,
blood and mucus, and the best source is an involved mesenteric node.
Serologic tests: increasing of special antibodies 4 times and more in paired sera (AR,
IHAR with diagnostic titles 1:200 and more), but commercially available tests or
standardized antigens are not available. Immune-enzyme analysis (ELISA test):
specific antibodies Ig M are positive in an acute phase of the disease.
Diagnosis example: Pseudotuberculosis, typical combined (scarlet fever +
arthralgic) form, moderate, uneven duration with exacerbation.
29
Differential diagnosis: scarlet fever, measles, viral hepatitis, typhoid fever,
paratyphoid fever, sepsis, enterovirus infection, bacterial diarrhea. Abdominal
syndrome must be differentiated from appendicitis, inflammatory bowel disease and
nonspecific intra-abdominal infections.
Treatment: Uncomplicated mesenteric adenitis due to Y. pseudotuberculosis is
a self-limited disease, and antimicrobial therapy is not required. Culture-confirmed
bacteremia should be treated with an aminoglycoside in combination with another
agent, as for infections due to Y. enterocolitica.
Prevention: Specific preventive measures other than avoiding exposure to
potentially infected animals and careful food-handling practices are not apparent.
INFECTIOUS ERYTHEMA (fifth disease)
Etiology: Infectious erythema occurs with Lyme borreliosis, yersiniosis,
tuberculosis, streptococcal infection. First of all, it is associated with parvovirus
B19, belonging to the family Parvoviridae. This is a DNA-containing virus
(parvum-small), called the number of the sample of human serum with which it
was first isolated.
Epidemiology: This disease primarily affects children aged 3 to 12 years,
although it can manifest in non-immune adults as rheumatic syndrome. Parvovirus
infection is ubiquitous, the spectrum of its clinical manifestations is extremely
wide - from maternal-fetal infection and severe systemic lesions (aplastic crisis,
hepatitis, myocarditis, arthritis, encephalitis) to mild forms in the form of
infectious erythema. For children, the course of the disease in the form of
infectious erythema, which is called Chamer erythema, the "fifth infectious
disease", is characteristic. Transmission: through secretion from the respiratory
tract, through blood or blood products, and vertical transmission from mother to
fetus. Persons suffering from erythema are most contagious before a rash appears.
30
Clinical manifestations: The incubation period from 4 days to 2 weeks.
A feature of infectious erythema is the appearance of the first elements of a
maculopapular rash on the face. The rash quickly merges, resembles a butterfly (“it
follows after a slap on the cheeks”) and within 2 days spreads to the trunk and
limbs, takes the form of stains and “garlands”. It is important that the rash is
mainly localized on the extensor surfaces of the limbs, trunk and neck, and the red
color of the rash quickly turns into bluish-red. The rash lasts from 5 to 9 days, is
accompanied by itching, but can characteristically recur within weeks to months
and be triggered by sunlight, exercise, temperature changes, bathing, or emotional
stress. Other clinical signs: normal or subfebrile body temperature, catarrhal
phenomena are absent or moderate. Arthropathy can occur in about 10% of
children and 60% of adults, it affects large joints asymmetrically.
The rash period is divided into 3 stages:
1. Erythema of the cheeks ("trace after a slap in the face").
2. Maculopapular rash in the form of a mesh "lace" pattern.
3. It lasts 2-3 weeks and is characterized by the periodic appearance of new
elements, itching, it can be triggered by swimming, sun exposure, and excitement.
Diagnosis: clinical. Detection of serum parvovirus B19-specific IgM antibody
is the preferred diagnostic test. Positive IgM test result indicates that infection
probably occurred within the previous 2 to 4 months.
PCR can detect viral DNA in clinical samples of urine, respiratory secretions, body
tissues and serum.
31
Differential diagnosis: a drug reaction, measles, rubella, scarlet fever,
enterovirus infection, and roseola infantum.
Complications: transient aplastic crisis in patients with chronic hemolytic
anemias, chronic erythroid hypoplasia with severe anemia. Human parvovirus B19
infection is of particular concern in pregnant women because it has been associated
with congenital anemia, fetal hydrops and subsequent fetal death.
Treatment: is supportive, at-risk patients may require transfusions or
intravenous immunoglobulin therapy.
Prevention: hand hygiene, avoidance of sharing eating utensils.
використання посуду.
SUDDEN EXANTHEMA
(exanthema subitum, sixth disease)
The etiology: human herpes virus (HHV) is of types 6 and 7 and belongs to
the genus of roseola viruses from the subfamily Betaherpesvirinae.
Epidemiology: Clinical symptoms appear in about 30% of children from the
age of 6 months. up to 2-3 years. It happens all year round. More common in late
autumn and early spring. Transmission: unknown (possibly due to secretion of
saliva and secretion from the nasopharynx).
Clinical manifestations: The incubation period is 5-15 days. Sudden
exanthema begins acutely with an increase in body temperature to 38-39 ° C, with
the absence of respiratory and local symptoms, sometimes an increase in the
cervical, behind the ear and other lymph nodes. The febrile period lasts mainly 3
days. Body temperature decreases critically, usually on the 4th day. After a
decrease in body temperature, a diffuse pink maculopapular or spotty rash appears
on the skin, which lasts up to 2-3 days. The rash is most often observed on the
trunk, neck. Sudden exanthema is often associated with the appointment of
32
antibiotics and therefore is mistakenly diagnosed with drug allergies. In all cases of
the appearance of a rash, the infectious etiology of the disease must first be
considered.
Diagnosis: clinically. Laboratory studies: CВC: leukopenia and less often
thrombocytopenia. PCR
Differential diagnosis: measles, rubella and other viral exanthema.
Complications: rarely febrile convulsions, meningitis and encephalitis.
Several cases have described fulminant hepatitis in primary HHV-6 infection.
The treatment is symptomatic.
Non-specific prevention.
ENTEROVIRUS INFECTION
Etiology: Coxsackie A16 virus, rarely A4-7, A9, A10, B2, B5 and enterovirus
71 of the Picornaviridae family from the genus Enterovirus.
Epidemiology: very contagious, mainly children under 10 years old are
affected, but can occur in young and middle-aged adults. Outbreaks occur every 3
years. In temperate climates, outbreaks occur during the summer. The virus may be
in the feces for several weeks. Human-to-human transmission via the fecal-oral
route.
Clinical manifestations: Incubation period is 5-15 days. Among the numerous
clinical forms of enterovirus infections (EVI), enterovirus exanthema (skin rash)
and enanthema (vesicles on the arches of the tonsils as herpetic tonsillitis) are
distinguished. So enterovirus-71, most often Koksaki A-16, causes viral exanthema
of the oral cavity and extremities (erysipelas syndrome), hand-foot-to-mouth
syndrome (Hand-Fuss-Mund Kianrheit). Elements of a rash appear on the 3rd day
of illness together with intoxication and fever. On the hands and soles vesicles up
33
to 1-3 mm with a corolla of hyperemia are observed; on the tongue, cheek mucosa
- aphthous elements, herpetic tonsillitis.
Enterovirus exanthema caused by ECHO, Coxsackie A and B viruses is
characterized by a polymorphic rash (spotted or spotted-papular). The rash appears
on the 1-2 day of the disease against a background of fever, which can be twowave. Rashes occur simultaneously on the skin of the face, body, less often on the
limbs, are stored for 1-2-3 days, and then disappear without a trace. Most often, the
rash occurs in children of the first years of life. Often, the rash can be combined
with other forms of enterovirus infection: diarrhea, myalgia, serous meningitis.
Diagnosis: clinically. Confirmation is possible by isolating the virus from
vesicles, nasopharyngeal secretions, cerebrospinal fluid, blood or biopsy materials.
Differential diagnosis: in the absence of exanthema, the differential diagnosis
includes herpes simplex virus, stomatitis and herpangin.
Complications: rare, but the Coxsackie virus can be associated with
myocarditis, meningoencephalitis, aseptic meningitis, paralytic disease and a
systemic disease resembling rubella. An infection in the first trimester of
pregnancy can cause a miscarriage.
Symptomatic treatment, including the optional use of various local
anesthetics to reduce oral discomfort. The vanilla ice cream diet is easier to
tolerate.
Non-specific prevention.
34
DIFFERENTIAL DIAGNOSIS OF INFECTIOUS DISEASES WITH
EXANTHEMA
Differential diagnostics of major maculopapular exanthemas
Signs
Onset /Initial
symptoms
Measles
Rapid onset, signs of upper
respiratory tract infections,
cough, conjunctives (with
photophobia) during first 24 days, general symptoms
Appearing
4-5 days, with stages
Characteristics
(morphology)
Maculo-papular, reddish
brown. Confluence most
prominent on face, trunk
1st day - on the face 2nd - on
the face, and trunk; 3rd day on the face, trunk, and
extremities, sparing the
palms and soles.
Localization/
distribution
Rash progression Typically, lasts 4 to 6 days
and disappear gradually in
order of appearance, leaving
a residual pigmentation
(yellow-tan coloration) or
faint desquamation.
hyperemia, enanthema,
Oral mucosa
Koplick's spots
Rubella
Occipital and
posterior neck
lymphadenopathy,
insignificant catarrhal
signs, and low grade
fever
1st day, rare – 2nd
small-papular, palerose
Scarlet fever
Acute onset - fever,
tonsillitis, neck
lymphadenitis, general
symptoms
1th day (in 20% - 2nd,
rarely – 3rd day)
small point-like, bright
and erythema
all skin, mainly on
extending surfaces of
the extremities.
begins on the superior
trunk and face; the
erythema quickly
spreads to the
extremities. Sparing
nose-labial triangle
(pale). Sometimes
petechiae in the
antecubital and axillary
skin folds (Pastia's
lines).
Disappear for 2-4 days The rash gradually turn
pale for 4-5 days,
desquamation after 10
days.
clear, sometimes
single elements of
enanthema
Intoxication/
General
symptoms
Labs criteria
significant, lasts 5-7 days
insignificant or absent
leucopenia, lymphocytosis,
aneosinophilia, positive
serological reaction with
measles antigen
leucopenia,
lymphocytosis,
increase number of
plasmatic cells,
positive serological
reactions with rubella
antigen
Complications
immunosuppression,
encephalitis
Noma of the cheeks
hyperemia, enanthema
or petechiae on palate,
tonsilitis, strawberry
tongue
proportional to local
signs, lasts 1-3 days
leukocytosis, shift to the
left, neutrophillosis,
increase ESR, in
pharyngeal, nasal swabs
– Strep.
toxic-shock–like state
Necrotizing fasciitis.
35
Differential diagnosis pseudotuberculosis and other exantems
Sign
Pseudotub
erculosis
Scarlet
fever
Infectious
mononucle
osis
Typhoid
fever
Enterovir
us
infection
Viral
hepatitis
Onset
Acute
Acute
Acute
Acute
Acute
Acute,
subacute
Initial sings
Toxic,
dyspeptic
and other
Sore throat,
toxic
Lymphopro
liferative,
toxic
Toxic
Catarrhal,
toxic
Catarrhal,
dyspeptic,
arthralgic,
asthenic
Rashes
Pin-point,
maculopapular,
erythema
Pin-point,
sand paper
maculouspapulous,
erythema
Single
reseals
Small
maculous
Rare (in case
of B
hepatitis)
Catarrhal
sign
Typical
Absent
Absent
Rare
Typical
In the initial
period
Oropharynx
Hyperemia
of the
pharynx
Tonsillitis
Tonsillopharyngitis,
posterior
rhinitis
Hyperemia
of the
oropharynx
Tonsillitis
Absent
Tongue
Coated,
strawberry
from the
4th-5th day
Coated,
strawberry
from the
4th-5th day
Coated
Coated
with grey,
teeth
excavation
Coated
Coated
Joints’
damage
Arthritis,
arthralgias
Not typical
Absent
Absent
Absent
Arthralgias in
the initial
period
Abdominal
pain
Around the
umbilicus
Absent
Absent
In the right
inguinal
region
Around the In the right
umbilicus
hypochondriu
m
Dyspeptic
syndrome
Typical
Rare
Absent
Constipatio
n, rare diarrhea
Typical
More
intensive in
prodromal
period
36
Hepatitis
May be
Absent
May be
Absent
Absent
Typical
Lymphoprol
iferative
syndrome
May be
Regional
lymphadeni
tis
Typical
Hepatosple
nomegaly
Absent
Hepato-, rare
splenomegaly
CNS
disorders
May be
Not typical
Not typical
Delirium,
sopor
May be
serious
meningitis,
encephaliti
s (rare)
Hepatic
encephalopat
hy in severe
case
Differential diagnostics of major petechial and vesicular exanthemas
Signs
Appearing
Pseudotubercullosis
(Yersiniosis)
Acute onset, with
polymorphism of
symptoms
(intoxication,
arthralgias, muscle
pain, intestinal
changes,
sore throat
2-8 day
Characteristics
(morphology)
Puncture-like, small
spots, erythema
Localization/
Distribution
"hood", "mitten",
"socks" signs, in skin
folds, bends, around
joints
Gradually disappear
for 2-5 days, small,
lamellar shelling
Possible hyperemia of
the pharynx, tonsils
Onset /Initial
symptoms
Rash
progression
Oral mucosa
Meningococcemia
Chickenpox
In some patients, the
prodrome 1 to 2 days
(nasopharhingitis).
Usually rapid onset
and progress,
significant general
symptoms
A mild prodrome lasting 1 to 2 days
before appearance of the rash.
Usually acute onset with fever,
rash, and general malaise
first hours of the
disease
Hemorrhagic "starlike" petechial rash
with necrosis in the
center.
In the early stages of
disease, the rash may
be maculopapular
(measles-like).
1-2 days, appear as pushes next 3-5
days
Polymorphic (spots, papules,
vesicles, crusts).
The lesions appear as erythematous
macules and progress to papules
and quickly evolve into vesicles.
The vesicles evolve into pustules,
which become umbilicated and
subsequently crust over in the
ensuing 8 to 12 hr. On physical
examination, lesions in all stages
may be present.
The rash typically begins on the
face, scalp or trunk and then
spreads to the extremities
A buttocks, lower
limbs, less - on the
trunk, hands, face
Small, disappear
gradually, significant,
leave necrosis
Hyperemia of the
pharynx, tonsils
hyperthrophy of
After desquamation of the crusts - a
slight pigmentation
An enanthema may be noted, and
vesicles may evolve to shallow
erosions, primarily on the palate.
37
Intoxication/
General
symptoms
Expressed, longlasting (2-3 weeks)
Other
symptoms
Arthritis, myocarditis,
diarrhea, hepatitis,
abdominal syndrome,
lymphoproliferative
symptom, nephritis,
nervous system
damage, pneumonia
Leukocytosis, shift to
the left, ESR
increases. Indirect
hemaglutination
reaction with special
diagnosticum,
detection of Y.
pseudotuberculosis
from feces.
Labs criteria
Complications
follicles
Prevalence, a high,
spiking fever,
tachypnea,
tachycardia and
hypotension.
Meningitis,
encephalitis, arthritis,
iridocyclitis,
endocarditis, aortitis,
pneumonia, pleurisy
Mild or moderate
Rare: generalized visceral forms,
meningoencephalitis
Leukocytosis, shift to
the left, neutrofilosis,
ESR increases.
Meningococci in
nasopharyngeal swab,
spinal fluid.
Leucopenia, lymphocytosis,
serological: positive binding
complement reaction with
Chickenpox antigen
Infection-toxic shock
Secondary bacterial infection of
excoriated lesions, encephalitis,
meningitis, transverse myelitis and,
rarely, Reye's syndrome,
myocarditis, corneal lesions,
nephritis, arthritis, bleeding
diatheses, acute glomerulonephritis
and hepatitis
QUESTIONS OF SELF-CONTROL
1. Measles. Etiology, epidemiology. Clinical manifestations. Complications.
Diagnostics. The principles of treatment. Prevention
2. Rubella. Etiology, epidemiology. Clinical manifestations. Diagnostics.
Treatment. Prevention
3. Chicken pox. Etiology, epidemiology. Clinical manifestations. Diagnostics.
Treatment. Prevention
4. Scarlet fever. Etiology, epidemiology. Classification. Clinical manifestations
of typical and atypical forms of scarlet fever. Complications. Diagnostics. The
principles of treatment. Prevention
38
5.
Pseudotuberculosis.
Etiology,
epidemiology.
Classification,
clinical
manifestations. Diagnostics. The principles of treatment. Specific preventive
measures. Epidemic measures at the source of infection.
6. Enterovirus infection. Etiology, epidemiology. Classification, clinical
manifestations. Diagnostics. treatment principles.
7. Sudden exanthema. Etiology, epidemiology. Classification, clinical
manifestations. Diagnostics. treatment principles
8. Infectious erythema. Etiology, epidemiology. Classification, clinical
manifestations. Diagnostics. The principles of treatment.
9. Differential diagnosis of infections with exanthema syndrome in children.
Tasks
Task 1. A boy of 3 years attends kindergarten. He became acutely ill: from a
rise in body temperature to 37.5 ° C and the appearance of a scalp, papular rash on
the skin of the scalp, trunk and extremities. The next day, individual elements of
the maculopapular rash formed into vesicles filled with transparent contents. On
the 4th day of illness, the child's condition is severe: body temperature 40C,
restless, refuses to eat, the number of skin rashes has increased. A significant zone
of skin hyperemia, tissue infiltration, and sharp pain appeared in the back. Pulse
140 per minute. Heart sounds are muffled. There are no meningeal symptoms.
Other organs without pathology. What disease can be expected in a patient?
Correct answer: Chickenpox, typical, severe, rash period. Complications:
phlegmon of the back. Typical symptoms: Polymorphism of the rash (spot, papule,
vesicle, crust), the presence of vesicles on the skin and oral mucosa, the presence
of a rash on the scalp.
Task 2. A girl of 2 years old, became ill sharply: her body temperature
increased to 39C, a cough, runny nose, conjunctivitis appeared. In the following
days, catarrhal phenomena increased, conjunctivitis became more pronounced,
photophobia appeared. On admission: moderate state, body temperature 38.2C,
sluggish. On the face, trunk, extremities - an abundant bright pink rash spotty39
papular, sometimes draining. Lymph nodes of all groups, especially cervical ones,
are enlarged, painless. Difficulty breathing through the nose, profuse mucopurulent
discharge. Wet cough. Conjunctivitis, lacrimation. Heart tones are loud, rhythmic.
The pharynx is wet, coated. The liver protrudes from the edge of the costal arch by
1 cm. The spleen is not palpable. The abdomen is soft, painless. The rumbling
along the intestine is determined. Diagnose and prescribe treatment.
The correct answer: Measles, typical, rash period, moderate. Complications:
bronchitis. The diagnosis was made on the basis of the following symptoms:
cyclical course of the disease, triad C (cough, runny nose, conjunctivitis), staged
rash, spotty-papular rash with a tendency to merge, intoxication. Treatment: bed
rest, eye toilet, oral cavity, vasoconstrictor drops in the nose, detoxification
therapy, measles immunoglobulin, isolation of the patient until the 10th day after
the rash appears.
Task 3. A girl, 8 years old, fell ill acutely from a rise in body temperature to
39C. General weakness, poor appetite, nausea, pain in the right iliac region, and a
rash on the body were noted. In the clinic, on the 3rd day of illness, the condition is
regarded as moderate to severe. On examination: puffiness and hyperemia of the
face and neck were determined. The tongue is covered with white coating, on the
cleaning sites - strowberry. On the skin, abundant rashes are located around large
joints, in the area of the hands and feet. In the lungs and heart - without deviations.
The abdomen is moderately swollen, with palpation, pain in the right iliac region is
determined. The liver is palpated 1.5-2.0 cm below the edge of the costal arch. The
spleen is not enlarged. The color of urine for 5 days was saturated, the color of
feces did not change. Biochemical analysis of blood: total bilirubin - 48 μmol / l,
conjugated - 30 μmol / l, ALT activity - 120 U / l, ALT - 80 U / l. No viral
hepatitis markers were found. Your preliminary diagnosis and its rationale?
Correct answer: Pseudotuberculosis, mixed form, moderate. The diagnosis
was made on the basis of the following symptoms: acute onset of the disease,
intoxication phenomena - temperature, loss of appetite, nausea, symptoms of
“hood”, “gloves”, “socks”, the characteristic location of the rash in the joints,
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“papillary” tongue. Enlarged liver with a violation of pigment metabolism,
cytolysis syndrome. General blood test - leukocytosis, neutrophilia with a shift in
the formula to the left, acceleration of ESR.
Task 4. A boy of 2 years old, attends kindergarten. The teacher in the group
got a sore throat. In the morning in the kindergarten, the child complained of pain
when swallowing, refused breakfast. Examined by a doctor: body temperature
37.3C. On the skin of the face, trunk, extremities, pink small-point rash with
saturation in the natural folds of the skin. In the throat, bright hyperemia. Enlarged
anterior cervical lymph nodes. The tongue is coated in white. With suspected
scarlet fever, the child was sent home. What laboratory diagnostic methods should
be prescribed in this case?
Correct answer: Clinical blood test, throat swab for group A streptococcus,
determine antistreptolysin titer, analysis of saliva for streptococcal antigens (Coagglutination reaction), urine analysis according to Nechiporenko, Zimnitsky test,
ECG.
Task 5. A child of 6 years old, became ill sharply with an increase in body
temperature to 38.50 ° C. The next day, the mother noticed a rash on her face,
trunk, and limbs. When examined by a local doctor: body temperature 37.8 C, an
increase and soreness of the cervical, occipital, axillary lymph nodes. The rash is
pink, small, papulose on the entire body, except for the palms and feet, with a
predominant location on the extensor surfaces of the limbs, without a tendency to
merge. When examining the oropharynx: there was an enanthem in the form of red
spots in the sky and palatine arches. Conjunctivitis and a rare cough were also
noted. There are no wheezing in the lungs. Heart sounds are expressive. The
abdomen is soft, painless. Liver, spleen - not enlarged. What is the preliminary
diagnosis? What diagnostic method will help establish the final diagnosis?
Correct answer: Rubella, typical. The rationale for the diagnosis: mild
intoxication, moderate catarrhal phenomena, a small rash without a tendency to
merge with predominant localization on the extensor surfaces of the limbs, an
increase in the cervical and occipital lymph nodes, enanthem. Studies to clarify the
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diagnosis: virological methods - the isolation of the virus from nasopharyngeal
swabs, blood, feces, urine. The serological method is the detection of antibodies
class M and G by ELISA, determining the avidity of antibodies, pH, RTGA, RSK,
RIF in dynamics, PCR.
TESTS
1. What is the mechanism of transmission of chickenpox
A. Airborne
B. transplacental
C. Fecal-oral
D. Alimentary
E. water
Correct answer: A
2. The rubella virus belongs to:
A. Rubivirus
B. Ortomyxoviruses
C.Hepadnavirus family
D.Herpesvirus family
E. Rhinovirus family
Correct answer: A
3. The first measles vaccination is recommended for children:
A. age 6 months and older
B. Newborns
C. 5 years and younger
D.12 months
E. regardless of age
The correct answer: D
4. The latent period of congenital rubella is:
A.1-3 days
B.30 days
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P.18-23 days
D.1 year
E.3-5 days
Correct answer: C
5. How many days should a chickenpox patient be isolated?
A. 5 days from the last element of the rash
B. 3-5 days
C. 1 month
D. 7 days
E. 14 - 21 days
Correct answer: A
6. Scarlet fever is characterized by:
A. A long period of fever precedes rashes
B. Spots in Koplik appear two days before the rash period
C. Synthetic penicillins provoke a rash
D. New elements of rash accompanied by fever
E. Skin desquamates in the second week after the appearance of rashes
Correct answer: A
7. In a child in whom there was pseudotuberculosis, 2 weeks after discharge, the
temperature increased, erythema nodosum appeared. Indicate its localization.
A. berries, hips, legs
B. forearms, arms, shoulders
C. Anterior and posterior surface of legs, thighs.
D. buttocks, hips, joints.
E. The front surface of the legs, around the joints, feet
Correct answer: D
8. Varicella Zoster virus belongs to:
A.Paramyxovirus family
B. Family of adenoviruses
C.Hepadnavirus family
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D.Herpesvirus family
E. Rhinovirus family
Correct answer: D
9. Epstein-Barr virus is characterized by severe tropism to:
A.CD3 lymphocytes
B.CD4 lymphocytes
C.T-lymphocytes
D.B-lymphocytes
E.NK cells
Correct answer: D
10. In children, the consequences of streptococcal group A pharyngeal infections
include everything except:
A. Fasting streptococcal glomerulonephritis.
B. Acute rheumatic fever.
C. Periodic fever syndrome.
D. Pandas (possibly).
Correct answer: C
REFERENCES
1.Manual of children's infectious diseases / O. Ye. Fedortsiv, I. L. Horishna,
I. M. Horishniy. - TERNOPІL : UKRMEDKNYHA, 2010. - 382 p. - ISBN 978966-673-145-9
2.Manual of Childhood Infections: The Blue Book (Oxford Specialist
Handbooks in Paediatrics) by Mike Sharland, Andrew Cant and al. Published
by Oxford University Press Inc., New York, 2011, p. 881 ISBN: 978-019-957358-5.
44
3.Учайкин В.Ф. Руководство по инфекционным болезням у детей/В.Ф.
Учайкин// М: ГЭЩЕФЗ-МЕД, 2001. – 824 с.
4.American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin
DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious
Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics;
2012:[online]
5.Belazarian L, Lorenzo ME, Pearson AL, Sweeney SM, Wiss KM,
"Chapter 192. Exanthematous Viral Diseases" Wolff K, Goldsmith LA, Katz SI,
Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine,
8e: http://accessmedicine.com/content.aspx?aid=56087223.
6.Centers for Disease Control and Prevention (CDC). Measles - United
States, 2011. MMWR Morb Mortal Wkly Rep. 2012 Apr 20;61:253-7. PubMed
PMID: 22513526.
7.Folster-Holst R, Kreth HW. Viral exanthems in childhood – infectious
(direct) exanthems. Part 1: Classic exanthems. Journal of the German Society of
Dermatology. 2009; 7:309-316.
8.Fölster-Holst R, Kreth HW. Viral exanthems in childhood--infectious
(direct) exanthems. Part 2: Other viral exanthems. J Dtsch Dermatol Ges. 2009
May;7(5):414-9. Epub 2008 Sep 19.
9.Mathes EF, et al. "Eczema coxsackium” and unusual cutaneous findings in
an enterovirus outbreak. Pediatrics. 2013 Jul;132(1):e149-57. PubMed PMID:
23776120.
10.James WD, Berger TG, Elston DM.
“Chapter 19. Viral Diseases”
(chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed.
Philadelphia, Pa: Saunders Elsevier; 2006: 394-397.
11.Jordan J. Clinical manifestations and pathogenesis of human parvovirus
B19 infection. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
12.Joseph M Lam Characterizing Viral Exanthems. Pediatr. Health. 2010;
4(6): 623-35. http://www.medscape.com/viewarticle/734882_2
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Навчальне видання
Ржевська Ольга Олександрівна
Кварацхелія Тамара Мерабівна
ДИФЕРЕНЦІЙНА ДІАГНОСТИКА
ІНФЕКЦІЙНИХ ЗАХВОРЮВАНЬ, ЩО СУПРОВОДЖУЮТЬСЯ
ЕКЗАНТЕМОЮ
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для 5 і 6 курсів медичного факультету (англ. мовою)
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Видавець і виготовлювач
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