Pediatric Exanthems and rashes

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Pediatric Exanthems and rashes
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Viral

• Classic
• I Measles (Rubeola)
• II Scarlet Fever
• III Rubella (German measles)
• IV Filatow-Dukes disease
• V Erythema Infectiosum
• VI Roseola Infantum

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• Other
• Herpes
• HSV 1 and 2
• Varicella-zoster
• Cytomegalovirus
• Epstein-Barr virus
• Human Herpes virus 6 and 7
• Human herpes virus 8
• Enterovirus
• Coxsackie A16
• Coxsackie A

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• Bacterial
• Group A Streptococcus
• Other
• Gianotti-Crosti
• Unilateral laterothoracic exanthem
• Pityriasis Rosea

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Measles

• Paramyxovirus
• Incubation period 7 14 days
• Infectious period 1- 2 days before prodrome to 4
  days after onset of rash
• Very infectious (90 attack rates in household
  contacts)
• Droplet spread oral secretions
• Typical course 7-10 days (without complications
• Risk factors non-vaccination

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Measles clinical features

• Prodrome day 7-14 after exposure
• Fever
• Cough
• Coryza
• Conjunctivitis
• Kopliks spots (1-2 days before rash)
• Rash (D3-7) started behind ears
• Miserable

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Measles Fever Triad
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Measles exanthem
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Measles complications

• Respiratory
• Common
• Secondary bacterial inftection
• OM
• LTB
• Cardiac
• Myocarditis
• Pericarditis
• ECG Changes

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Measles Complications

• Neurological
• Abnormal EEG common
• Encephalitis
• 11000
• Usually during exanthem
• 25 sequalae
• CSF increased wcc (pleocytosis), protein

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Measles Complications

• Others
• Black measles (haemorrhagic skin eruption)
• SSPE
• 0.6/100,000
• Mean incubation 7 years
• Increased CSF IgG
• 6-9 months until death
• Keratitis (blindness)

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Measles diagnosis

• Serology
• IgM
• Detectable 3 30 days after exanthem
• IgG
• Detectable from 7 days after the exanthem appears

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Scarlet Fever

• Group A beta-haemolytic streptococcus
• Primary
• Pharyngitis
• Skin
• Cellulitis
• Impetigo
• Non-Suppurative complications
• Scarlet fever
• Streptococcal toxic shock syndrome
• Acute glomerulonephritis
• Acute rheumatic fever
• Suppurative complications
• Tonsillar abscess
• OME
• Necrotizing fasciitis

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GAS

• Aerobic gram-positive coccus
• Forms chains

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Scarlet Fever

• Symptoms of primary infection, ie pharyngitis
• Strawberry tongue
• Perioral pallor

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Scarlet fever Rash
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Scarlet fever rash
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Scarlet Fever rash
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Streptococcal Toxic Shock Syndrome

• Definition GAS infection associated with the
  acute onset of shock and organ failure
• Virulence factors
• M protein (Type 1, 3, 12, 28 most commonly
  isolated)
• Anti-phagocytic, cell membrane protein
• Exotoxins (SPEA, SPEB)
• Streptococcal pyrogenic exotoxin A,B
• Trigger inflammatory cytokine release

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Streptococcal Toxic Shock Syndrome Clinical
Features

• Fever
• Hypotension
• Altered mental status (50)
• Multiorgan dysfunction
• Renal (All)
• ARDS 55
• Influenza-like syndrome (20)
• Soft tissue infection
• Progresses to fasciitis/myositis 70-80
• Scarlatinaform rash (10)

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Staphylococcal toxic shock syndrome vs
Streptococcal

• Findings Staph Strep
• Age 15-35 20-50
• Sex FgtM FM
• Local invasive
• Disease Absent Present
• Generalized
• Erythroderma Present Absent
• N/V/D Present Absent
• Bacteraemia Uncommon 60
• Mortality 3 30

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Streptococcal Toxic Shock Syndrome Diagnosis

• Working Group on Severe Streptococcal Infections
• Isolation of GAS from a normally sterile site
• Plus
• Hypotension
• Plus gt 2 of the following
• Renal impairment
• Coagulopathy
• Liver impairment
• ARDS
• Erythematous macular rash, may desquamate
• Soft tissue necrosis

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Rubella

• Togavirus
• Incubation period 2 - 3weeks
• Transmission droplet

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Rubella Clinical Features

• Mild/subclinical
• Prodrome
• Eye pain, conjunctivitis, headache, fever,
  malaise
• Rash
• Maculopapular
• Starts on face, spreads caudally to trunk,
  extremities
• Similar to Measles, but spreads quicker
• Lymphadenopathy
• Posterior cervical, posterior auricular,
  suboccitpital
• Forchheimer spots (20)
• Petechiae on soft palate

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Rubella complications

• Joints
• Arthralgia/arthritis
• Rare in children
• Lasts about 9 days
• Neurological
• Encephalitis rare
• 2-4 days after rash
• Parasthesia
• Other
• Thrombocytopaenia
• Purpura
• Myocarditis
• Testicular pain
• Haemolytic anaemia

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Rubella Diagnosis

• Serology
• Rubella IgM (false positive EBV, CMV)
• Follow-up serology 4 weeks (paired sera)
• Treatment
• Supportive

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Erythema Infectiosum

• Parvovirus B19
• Common 5-10 aged 2-5 seropositive
• Incubation
• 4 14 days
• Replicates in erythroid progenitor cells in bone
  marrow/blood ? anaemia

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Erythema Infectiosum Clinical

• Biphasic illness
• Non-specific prodrome (fever, headache, myalgias
  (5-7 days after infection)
• 1 week later rash (slapped cheek, reticular
  rash extremities)
• Papular-pruritic glove and sock syndrome
• Arthritis/arthralgia
• Aplastic crisis

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EI rare manifestations

• Arthritis
• Association b/w B19 and RA
• Neurological
• Encephaliis
• Meningitis
• GB syndrome
• Facial palsy
• CT syndrome
• Myocarditis
• Cutaneous
• EM
• HSP
• Petechiae
• Haematological
• TTP
• Pancytopaenia
• Haemophagocytic
• DB anaemia

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EI Slapped cheek
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Parvovirus B19 reticular/lace rash
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Papular-pruritic glove and sock syndrome
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EI Treatment

• Paracetamol, Ibuprofen
• IVIG only in patients with aplasia
• Supportive

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HHV 6 Roseola Infantum

• DNA virus
• Sixth disease
• Incubation 9 days
• Transmission oral secretions
• 80 children seropositive by age 1
• Peak infection 9 21 months

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HHV6 Clinical

• Fever and convulsion (6-15)
• Diarrhoea (70)
• Usually well
• Rash
• evolves over 12 hours, fades 2-3 days
• Appears as fever abates
• Starts on neck/trunk, spreads to extremities
• Erythematous, blanching, macular/mac-papular
• Bulging fontanelle (25)

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HHV6 Rash
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HHV6 treatment

• Supportive
• Anti-virals in immunocompromised

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Varicella Zoster

• DNA virus
• Incubation 10-21 days
• Tramission Droplet
• Highly infectious (1-2 days before rash, until
  crusts)

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Chickenpox clinical

• Prodrome
• Fever
• Headache
• Malaise
• Pharyngitis
• Rash
• Pruritic
• Macules ? papules ? vesciles
• Hairline

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Chickenpox Rash
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VZV Chickenpox Complications

• Skin
• Cellulitis (GAS)
• Neurological
• Encephalitis
• Acute cerebellar ataxia (14000)
• Diffuse encephalitis (1100,000)
• Reye Syndrome
• No salicylates
• N/V, headache, excitability, delirium
• Respiratory
• Pneumonia (SA, GAS)
• Zoster

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CMV

• DNA virus (HHV)
• 60-70 seroprevalence
• Infection usually asymptomatic
• Most improtant cause of congenital infection
• Important in immunocompromised hosts
• Associated with malignant transformation

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CMV Clinical

• Immunocompetent
• 90 asymptomatic
• Fever and lethargy up to 4 weeks
• Usually self-limiting
• Immunocompromised
• CMV pneumonitis (90 mortality)
• GIT disease
• CMV retinitis

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CMV Diagnosis, Treatment

• Diagnosis
• PCR and CMV antigenaemia
• Treatment
• Nucleosides (Target DNA polymerase)
• Ganciclovir and cidofovir
• Foscarnet

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ZIG immunoglobulin

• Indications
• Neonates whose mother develops VZV from 5 days
  prior to 2 days after delivery
• Neonates if mother no history or negative
  serology
• Premature infants lt 28/40
• Where vaccine may be contrindicated

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Enteroviruses

• Picornaviridae family
• RNA virus
• Transmission
• Faecal-oral
• Respiratory secretions (CoxsackieA21)
• Droplets (Enterovirus 70)

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Enterovirus

• Poliovirus subclinical, aseptic meningitis,
  paralytic poliomyelitis
• Non-polio virus
• Coxsackie A HFMD, Herpangina
• Coxsackie B Herpangina, pleurodynia,
  myocarditis, pericarditis, meningoencephal
  itis
• Echovirus URTI, aseptic meningitis, acute
  haemorrhagic conjunctivitis
• Enterovirus Gastroenteritis

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Herpangina

• Coxsackie A16, Enterovirus 71
• Mainly 3-10yo
• Fever, sore throat, odonyphagia
• Vesicular enanthem on the tonsillar fauces, soft
  palate, posterior pharynx
• Conservative, symptomatic Rx

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HMFD

• Coxsackie A16, enterovirus 71
• Summer
• Hihgly infectious
• Prodrome
• Vesicular eruptions of hands, feet, oral cavity
• Conservative, symptomatic Rx

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Pityriasis rosea

• ?viral aetiology
• Mulitple viruses implicated
• Often viral prodrome
• Herald patch
• Single scaling patch
• Appears 1-21 ays prior to general rash

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Herald patch
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Herald patch
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Pityriasis rosea

• Scaly patches/plaques
• Chest and back
• Uncommon on face/scalp
• Smaller than herald patch
• Follow Langers lines
• Collagen bundle direction
• Christmas tree distribution
• Pruritic (75)

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Pityriasis rosea
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Pityriasis rosea
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Langers Lines
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Distribution along Langers lines
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Pityriasis rosea

• Symptomatic treatment
• Lasts 6-12 weeks
• Some cases photosensitive
• ?non-infectious

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Pityriasis lichenoides

• ?Aetiology
• Post-infectious
• T-cell lymphoproliferative disorder
• Immune-complex mediated hypersensitivity
  vasculitis
• Pityriasis lichenoides chronica (PLC)
• Pityriasis lichenoides et varioliformis acuta
  (PLEVA)

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Pityriasis lichenoides (PLC)

• Various stages
• Small pink papule ? reddish-brown
• A fine mica-like adherent scale attached to a
  central spot
• Spot flattens out spontaneously leaving behind a
  brown mark, which fades over months
• Commonly trunk, buttocks, arms, legs
• Not itchy/irritable

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Pink papule
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Scaly plaque
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PLEVA

• Red patches that evolve quickly into papules
  5-15mm diameter
• Often covered in mica-like scale
• Papules can contain pus/blood
• Trunk , extremities commonly, but can be
  widespread
• Pruritic and burning sensation

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PLEVA
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Kawasaki Disease

• Systemic vasculitis
• Aetiology
• Still unkown
• Predominantly lt 5yo
• Diagnostic criteria
• Fever for 5 days
• PLUS 4 of 5
• Polymorphous rash
• Bilateral (non purulent) conjunctivitis (90)
• Mucous membrane changes
• Erythema, fissuring of lips
• Strawberry tongue
• Peripheral changes
• Erythema of palms/soles
• Oedema of hands/feet
• Desquamation in convalescent phase
• Cervical lymphadenopathy (75)
• gt15mm
• Usually unilateral, single, painful

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Important complication

• Coronary artery abnormalities
• Aneurysms
• An unfavourable outcome
• Related to duration of fever

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Atypical Kawasaki disease

• Usually at extremes of age
• Additional diagnostic criteria to aid in
  diagnosis
• ?associated with higher rate of coronary artery
  complications

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Rash

• Polymorphous
• Macular/papular/morbilloform/scarlatiniform/urtica
  rial/erythrodermatous
• Never vesicular or bullous
• Associated with desquamation of perineal region
  days later

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Polymorhous rash
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Mucous membrane changes
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Conjunctivitis
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Palmar erythema
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Peripheral oedema
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Investigations

• FBE
• Neutrophilia
• Thrombocytosis
• Normochronic, normocytic anaema
• ASOT
• CRP
• ESR
• LFT
• Hypoalbuminaemia
• Elevated liver enzymes
• Echocardiogram

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Management

• IVIG
• 2g/kg over 10 hours
• Preferably within first 10 days of illness
• Aspirin
• 3-5mg/kg once a day for 6-8weeks
• For coronary complications