Dr(Mrs) M.S.Panapitiya
Consultant Paediatrician
why
• Viral exanthum
• Serious illness
Main features
• Well child / ill child
• Erythematous / haemorrhagic rash
Diagnostic clues
• Association with fever
• Distribution
• Morphology
Classfication of rashes
• Mobiliform rashes
• Scarlantiform rashes
Rash that looks like measles
Patients with
Kawasaki disease
drug reactions
The rash consists
macular lesions
red
2-10 mm in diameter
may be confluent
papular lesions
solid
elevated above the rest of the skin
• Has the pattern of
scarlet fever
• has innumerable small
red papules
• Patients with other
conditions such as
Kawasaki
disease
viral infections
drug reaction
• VIRAL INFECTIONS
• BACTERIAL INFECTIONS
• NONINFECTIVE
Chicken pox
Hand foot mouth disease
Measles
Rubella
Fifth disease
Sixth disease
Dengue fever
Erythema infectiousum
Parvovirus B19
The preceding four exanthems were
1. Measles
2. Scarlet fever
3. Rubella
4. Atypical Scarlet fever ( Filatov-Dukes disease)
6. Roseola infantum (sixth disease)
Benign, self-limited exanthematous
illness of childhood.
The prodromal phase
• low-grade fever
• headache
• mild upper respiratory
tract infection
Characteristic rash
occurs in three stages
1.erythematous facial
flushing
"slapped-cheek"
appearance.
2. Spreads rapidly to the
trunk and proximal
extremities as a diffuse
macular erythema
3. Central clearing of macular
lesions occurs
giving the rash a lacy,
reticulated appearance.
Palms and soles are spared,
more prominent on extensor
surfaces
rash resolves spontaneously
without desquamation
Exanthem subitum
Sixth disease
Human herpes virus 6 (HHV-6)
Primary HHV-6 infection occurs early in life.
Peak acquisition of primary HHV-6
infection, from 6-15 m of age
By 3-5 yr, 80-100% of children are seropositive
The prodromal period
•
usually asymptomatic but may
include
•
mild upper respiratory tract signs
•
mild conjunctival redness
•
cervical or, less frequently, occipital
lymphadenopathy
•
mild palpebral edema.
Clinical illness
101-106°F with an average of 103°F
irritable and anorexic
Seizures may occur in 5-10% of children
Infrequently abdominal pain, vomiting,
and diarrhea.
Fever persists for 3-5 days, and then typically
resolves rather abruptly (crisis)
A rash appears within 12-24 hr of fever
resolution
Begins as discrete, small (2-5 mm), slightly
raised pink lesions on the trunk and spreads to
the neck, face, and proximal extremities
Not pruritic, and no vesicles or pustules
remain discrete but occasionally may become
almost confluent.
After 1-3 days, the rash fades.
(rubeola)
Measles has three clinical stages
Incubation stage 10-12 days
Prodromal stage 2- 4 days
Disease stage
6-10 days
prodromal phase
characterized by
•
low-grade to moderate fever
•
conjunctivitis
•
coryza
•
dry cough
•
red mottling on the hard & soft palate
•
Koplik spots
Koplik spots
The pathognomonic sign of measles,
appear by 2-3 days
Grayish white dots, usually as small as
grains of sand
Opposite the lower molars
They appear and disappear rapidly,
usually within 12-18 hr.
EXANTHEMATOUS PHASE
The temperature rises
abruptly as the rash
appears
neck, behind the ears,
along the hairline, and on
the posterior parts of the
cheek
Lesions
macular, maculopapular
confluent,haemorrhagic
Spreads rapidly over the
entire face, neck, upper
arms, and upper part of
the chest within the
first 24 hr
• Mx
•
•
•
•
•
admit
iv fluids
vit A
antiotics
NUTRITION
• Complictions
pneumonia
diarrhoea
malnutrition
blindness
encephalitis
death
(German or three-day measles)
The incubation period is 1421 days
The prodromal phase of mild
catarrhal symptoms is shorter
than that of measles and may
go unnoticed
Two thirds of infections are
subclinical.
RUBELLA
Lymphadenopathy.
most characteristic sign
retroauricular, posterior cervical, and
occipital
An enanthem
appears in 20% of patients just before
the onset of the skin rash.
discrete rose-colored spots on the soft
palate (Forchheimer spots)
Exanthem
•It begins on the face and
spreads quickly.
•Discrete maculopapules are
present in large numbers
•Spread rapidly over the entire
body, usually within 24 hr.
•May be confluent
•The eruption usually clears by
the third day.
•Rubella without a rash has been
described.
Coxsackievirus A
Coxsackie B viruses
Enterovirus 71
It is usually a mild illness, with or without low-grade
fever.
The oropharynx is inflamed and contains scattered
vesicles on the tongue, buccal mucosa, posterior
pharynx, palate, gingiva, and/or lips.
These may ulcerate, leaving 4-8 mm shallow lesions
with surrounding erythema.
Develop the rash on the
palms of the hands,
soles of the feet,
maybe on buttocks.
Rash is not itchy,
Starts out as small, flat, red dots
turn into bumps or blisters(3-7mm)
They are generally more common
on the extensor surfaces
Vesicles resolve in about 1 week
Mx
Symptomatic
No specific therapy
Vricella-Zoster Virus
Patients are
contagious 24-48 hr
before the rash
appears
and until vesicles are
crusted,
usually 3-7 days after
onset of rash
Prodromal phase
24- 48 hr before the rash
malaise, headache, anorexia
fever - variable
- resolves 2-4 days after
the onset of the rash
•The rash often appears first
on the scalp, face, or trunk.
•It can then spread over the
entire body.
Ulcerative lesions involving
the oropharynx are common
Vricella-Zoster Virus The initial exanthem
The initial exanthem
• Intensely pruritic
• Erythematous macules
• Papular stage
•
•
Blisters on a pink base
Dry brown crusts
•
New waves of blisters often
spring up as the illness
progresses
Vricella-Zoster Virus
Varicella is a more
serious disease with
higher rates of
complications and deaths
among infants, adults,
and
immunocompromised
patients.
Newborn with varicella
Newborns have particularly high
mortality around the time of
delivery.
Maternal varicella one week before or 2
days after birth frequently results in the
newborn developing severe varicella
The initial infection is intrauterine,
although the newborn often develops
clinical chickenpox postpartum.
Newborn with varicella
Rx : ZSIG
IV Acyclovir
CONGENITAL VARICELLA
SYNDROME
Up to 2% of fetuses whose
mothers had varicella in the first 20
weeks of pregnancy may
demonstrate VZV embryopathy
Fetuses infected
at 6-12 wk of gestation appear to have
maximal interruption with limb development
at 12-20 wk may have eye and brain involvement
Stigmata of Varicella-Zoster Virus Fetopathy
Cicatricial skin lesions
Hypopigmentation
Microphthalmia
Cataracts
Chorioretinitis
Optic atrophy
Microcephaly
Hydrocephaly
Calcifications
Aplasia of brain
Hypoplasia of an extremity
Motor and sensory deficits
Absent deep tendon reflexes
Skin
Eye
Brain
Limbs
Varicella vaccine
•
•
•
•
Live virus vaccine
Recommended for children at 12-18 mo
Can be given at any age
Children 12 mo to 12 yr receive a single
vaccine dose
• Adolescents and adults require 2 vaccine
doses, a minimum of 4 wks apart
Breakthrough varicella
2-6 weeks after vaccination
Could be due to either the wild
or vaccine strains
Usually very mild
Potentially infectious
Upper respiratory tract infection
associated with a characteristic rash
Infection with pyrogenic exotoxin
producing group A streptococcus
The rash
appears within 24-48 hr after onset
of upper respiratory symptoms
begins around the neck and
spreads over the trunk and
extremities
Diffuse, finely papular,
erythematous eruption
producing a bright red
discoloration
Blanches on pressure
More intense along
the creases of the
elbows, axillae, and
groin
P
Cheeks may be
erythematous with pallor
around the mouth.
Pharynx is red
The tongue is usually coated and
the papillae are swollen
After desquamation, the reddened
papillae are prominent, giving the
tongue a strawberry appearance.
After 3-4 days, the rash begins to
fade and is followed by
desquamation
Sheetlike desquamation may
occur around the free margins
of the fingernails, the palms,
and the soles.
Treatment
•Group A streptococcus is sensitive to
penicillin, and resistant strains have never
been encountered.
•Penicillin is, therefore, the drug of choice
(except in patients who are allergic to
penicillin)
•Treatment with oral penicillin V for 10 days is
recommended
•It must be taken for a full 10 days even
though there is symptomatic improvement
in 3-4 days
Toxic shock syndrome is caused by
a toxin produced by certain types of
Staphylococcus bacteria.
A similar syndrome, called toxic shock-like
syndrome (TSLS), can be caused by
Streptococcal bacteria.
The onset is abrupt
high fever
vomiting
diarrhea
sore throat
headache
myalgia
Very ill
Alteration in the level of
consciousness
Oliguria, hypotension
progress to shock
Disseminated intravascular
coagulation
• Exanthum
A diffuse erythematous macular rash
(scarlatiniform) appears within 24 hr
Hyperemia of pharyngeal&
conjunctival, mucous membranes
Strawberry tongue is common
Diagnostic criterias
Fever lasting for at least 5 days
Fever lasting for at least 5 days
Presence of at least four of the following
five signs:
1. Bilateral
bulbar
conjunctival
injection,
generally
nonpurulent
2. Changes in
the mucosa of
the oropharynx,
injected pharynx
red, dry & fissured lips
strawberry tongue
3.Changes of the
peripheral
extremities
Edema and/or erythema of
the hands or feet in the
acute phase
Periungual desquamation in
the subacute phase
4.Rash,
primarily truncal
polymorphous but
nonvesicular
Rash of various forms
(maculopapular, erythema
multiforme, or scarlatiniform)
with accentuation in the groin
area
5.Cervical adenopathy,
≥1.5 cm
usually unilateral
nonpurulent
Mycoplasma pneumoniae
• Skin lesions include a variety of exanthems,
most notably
Maculopapular rashes
Erythema multiforme
Stevens-Johnson syndrome
Dengue fever rash
A transient, macular, generalized rash that
blanches under pressure may be seen during
the first 24-48 hr of fever.
A generalized, morbilliform, maculopapular
rash appears that spares the palms and soles.
Rarely there is edema of the palms and soles.
Petecial rash - Usually found on the limbs this
rash is as a result of bleeding under the skin
surface.
Bright red rash - skin becomes florid and bright
red in appearance. there will be some 'normal'
areas of skin which are unaffected.
?TRANSIENT APLASTIC CRISIS
•The incubation period for is shorter than
for erythema infectiosum because it
occurs coincident with the viremia.
•B19-induced
aplastic
crises occur in
TRANSIENT APLASTIC
CRISIS.
patients with all types of chronic
hemolysis
•These patients are ill with fever, malaise,
and lethargy and have signs and
symptoms of profound anemia
•Rash is rarely present.
C0NGENITAL INFECTION
(PARVOVIRUS B19)
Primary maternal infection is associated with nonimmune fetal
hydrops and intrauterine fetal demise
The mechanism of fetal disease appears to be a viral-induced red
cell aplasia at a time when the fetal erythroid fraction is rapidly
expanding.
The second trimester seems to be the most
sensitive period, but fetal losses are reported
at every stage of gestation
• probably the most common cause of stomatitis in children 1-3 yr of
age,
• The symptoms may appear abruptly, with pain in the mouth,
salivation, fetor oris, refusal to eat, and fever, often as high as 4040.6°C
• Fever and irritability may precede the oral lesions by 1-2 days.
• The initial lesion is a vesicle which is seldom seen because of its
early rupture.
• The residual lesion is 2-10 mm in diameter and is covered with a
yellow-gray membrane.
• the tongue and cheeks are most commonly involved, no part of the
oral lining is
• Submaxillary lymphadenitis is common.
• The acute phase lasts 4-9 days and is self-limited
reatment
Any foreign materials, such as tampons,
vaginal sponges, or nasal packing, will be
removed. Sites of infection (such as a surgical
wound) will be drained.
The goal of treatment is to maintain important
body functions. This may include:
Antibiotics for any infection (may be given
through an IV)
Dialysis (if severe kidney problems are present)
Fluids through a vein (IV)
Methods to control blood pressure
Intravenous gamma globulin may help in
severe cases
Dukes' disease
or fourth disease
An exanthem-producing infectious
disease of childhood of unknown
aetiology.
Synonym: Filatov's disease, fourth
disease,
Signs and tests
No single test can diagnose toxic shock
syndrome.
The diagnosis is based on several criteria:
fever, low blood pressure, a rash that peels
after 1-2 weeks, and problems with the
function of at least three organs.
In some cases, blood cultures may be positive
for growth of S. aureus.
Treatment