Common Exanthems

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Common Exanthems

• Adam Goldstein, MD
• Associate Professor
• UNC Department of Family Medicine
• Chapel Hill, NC
• aog_at_med.unc.edu

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Objectives

• Understand nomenclature for common exanthems
• Know an appropriate differential dx for most
  exanthems
• Improved ability to diagnose
• Measles (rubeola)
• German Measles (Rubella)
• Chicken Pox (Varicella)
• Fifth Disease (Erythema infectiosum)

• Roseola (exanthem subitum)
• Hand, foot mouth disease
• Pityriasis rosea
• Asymmetric periflexural exanthem of childhood
  (APEC)
• Kawasaki disease
• Smallpox
• Scarlet fever
• Drug eruptions
• Unknown exanthems

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Exanthems

• Anyone of a number of systemic processes giving
  generalized eruption
• Usually not isolated
• Caused by
• Viruses
• Bacteria
• Fungal
• Drugs
• Idiopathic

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Exanthems (Historical)

• 1 Measles
• 2 Scarlet fever
• 3 Rubella
• 4 "Dukes' disease- ? measles, rubella, scarlet
  fever, Staph infection, or one of several
  unspecified enteroviral infections
• 5 Erythema Infectiosum
• 6 Roseola.

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Measles (Rubeola)

• Diff Dx
• S/Ss Fever, conjunctivitis, cough
• Characteristic Koplik spots 24-48 hours before
  rash
• Rash
• Days 4-5, red blotchy
• begins on face behind ears
• usually with onset high fever
• spreads to body
• Usually spares palms/soles
• Rash coalesces on trunk/face

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Rubella (German measles)

• "little red 3rd Disease
• Schoolchildren highest infectivity in
  unvaccinated populations
• Congenital Rubella Syndrome
• deafness, eye lesions, heart malformations mr
• 24 cases 1997-1999, mostly immigrant
• 25-50,000 cases Mexico 1998
• Higher suspicion cases in patients immigrating
  from countries with higher rates
• Vaccination contraindicated pregnancy

(MMWR, 2001)
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Rubella

• Diffuse rash, LN enlargement, h/a, malaise, mild
  cough and conjunctivitis
• Pink rash appears on face and spreads to body

www.info.gov.hk/dh/diseases/ CD/rubella.htm
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Chicken Pox- Varicella

• caused by varicella-zoster virus
• blister-like rash, itching, fatigue fever
• 250-500 itchy blisters, 3 stages at same time
  (papule, vesicle, scab)
• 1 in 10 complications bacterial, pneumonia,
  encephalitis

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Chicken Pox- Varicella
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Fifth Disease (Erythema infectiosum)

• Parvovirus B19
• S/Ss low fever, cold, mildly ill
• Skin
• "slapped-cheek" rash on face
• lacy red rash trunk limbs
• infected adults may develop joint pains hands,
  wrists, knees
• kids may return to school- no longer infectious
• pregnant women exposed- refer to guidelines

(Crane J, J Obstet Gynaecol Can, 2002)
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Roseola/Exanthem Subitum

• Human Herpes Virus 6gt7
• spread via saliva
• 72-95 sero in US early age
• S/Ss irritable, diarrhea, cough, fever
  102-105F, for 3-7 days 10 seizure
• Skin
• As fever resolves, faint macules develop on trunk
  and extremities that blanch upon pressure
• Rash resolves 1-2 days

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Roseola/Exanthem Subitum

• Skin
• As fever resolves, faint macules develop on trunk
  and extremities that blanch upon pressure
• Rash resolves 1-2 days

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Hand Foot and Mouth Disease

• Common acute febrile illness of children
• Group A coxsackie viruses
• 2-7 days resolves
• Hand washing
• Rare complications

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HFM Disease

• hand
• foot
• mouth

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Pityriasis rosea

• Unknown cause
• Lasts 6-12 weeks
• Herpes viruses 6 7 associated
• Herald patch 1-20 days before rash
• Sometimes confused with T. Corporis or psoriasis

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Pityriasis rosea

• Oval patches follow line of ribs like fir tree
• Erythromycin may be effective tx

(Sharma, JAAD, 2000)
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Asymmetric periflexural exanthem of childhood
(APEC)

• Laterothoracic exanthem
• Uncommon, G gt B
• Viral symptoms can occur
• Often mistaken for eczema, fungal
• Skin
• Usually starts in armpit or groin and extends
  outwards, on one side of body
• May spread to face, genitalia, hands or feet
• Patches are net-like or in rings
• Pruritic
• Resolves within 3 months

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Kawasaki disease

• 80 in children lt 4 years
• Self-limiting resolves spontaneously without
  treatment 4-8 weeks
• 15-20 have damage to coronary arteries and 2 of
  patients die from heart attack

(Brogan PA, Arch Dis Child, 2002)
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Kawasaki disease
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Kawasaki disease
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Kawasaki disease
http//www.dermnetnz.org/index.html
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Smallpox

• Classic generalized exanthem
• Latin word for spotted referring to the raised
  bumps on the face and body
• Rash, high fever mortality rate 30
• Last natural case Somalia in 1977

http//www.bt.cdc.gov/agent/smallpox/overview/dise
ase-facts.asp
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Smallpox

• Exanthem from vaccination
• 1/100,000
• Vaccinia rash or outbreak of sores
• Generalized vaccinia
• Erythema multiforme

http//www.bt.cdc.gov/agent/smallpox/
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Smallpox

• From Vaccination
• 1/50,000
• Eczema vaccinatum
• Progressive vaccinia
• Postvaccinal encephalitis

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Scarlet fever

• Group A streptococcus toxin
• children aged 4-8
• contagious by coughing/sneezing or touching the
  infected skin
• sudden fever with sore throat, swollen LNs, h/a,
  n, v, loss of appetite, swollen and red
  strawberry tongue, abdominal pain, body aches,
  and malaise

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Scarlet fever

• Skin
• rash 12-48 hours after fever
• ears, neck, chest, armpits, groin, then rest of
  body over 24 hours
• scarlet spots or blotches, often the first sign
• starts to look like sunburn with goose pimples
• skin may have a rough sandpaper-like feel
• as rash fades, it peels similar to that of
  sunburned skin

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Drug eruptions

• Almost all drugs

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Drug eruptions

• Dilantin

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Drug eruptions

• Minocycline

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Drug eruptions

• Fixed drug eruption

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Unknowns 1
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Unknowns 2
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Unknowns 3
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Unknowns 4
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Unknowns 5
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Unknowns 6
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Unknowns 7
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Unknowns 8
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Unknowns 9
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Unknowns 10
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BONUS
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BONUS
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BONUS
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References

• Trizna Z. Viral diseases of the skin diagnosis
  and antiviral treatment. Pediatr Drugs
  200249-19.
• http//home.mdconsult.com/das/guideline/view/26827
  010/N/11196820?sid166362089sourceMI
• Crane J. Parvovirus B19 infection in pregnancy. J
  Obstet Gynaecol Can 2002 24 727-43.
• Glatman-Freedman A. Rubella vaccine. Pediatr Rev
  2002 23(3) 106-7.
• Smallpox Vaccine. Pediatrics 2002. American
  Academy of Pediatrics, Committee on Infectious
  Diseases 110 4.
• Bromberg K. Group A beta-hemolytic streptococcal
  pharyngitis. Am Fam Physician 2001 63(8)
  1486-7.
• Bisno AL. Practice guidelines for the diagnosis
  and management of group A streptococcal
  pharyngitis. Infectious Diseases Society of
  America. Clin Infect Dis 2002 35(2) 113-25.

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References

• Gable EK. Pediatric exanthems. Prim Care 2000
  27 353-69.
• Brogan PA. Kawasaki disease an evidence based
  approach to diagnosis, treatment, and proposals
  for future research. Arch Dis Child 2002 86
  286-90.
• Hairston BR. Viral diseases of the oral mucosa.
  Dermatol Clin 2003 21(1) 17-32.
• De Araujo T. Human herpesviruses 6 and 7.
  Dermatol Clin 2002 20(2) 301-6.
• Sharma PK. Erythromycin in pityriasis rosea A
  double-blind, placebo-controlled clinical trial.
  J Am Acad Dermatol 2000 42 241-4.
• MMWR. Control and prevention of rubella
  evaluation and management of suspected outbreaks,
  rubella in pregnant women, and surveillance for
  congenital rubella syndrome. July 13, 2001 50
  1-23.

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Thank you.