Download Common viral Exanthems

Crash Course on Common Viral Exanthems
(now with CASES!)
Vincent Patrick Tiu Uy, MD
PGY-2
Pediatrics
St. Barnabas Hospital, Bronx
 Define Exanthem VS Enanthem
 Short and Sweet case
 Identification of the disease and causative agent
 Chronology of Signs and Symptoms
 Incubation & Period of contagiousness
 Work-up
 Treatment and Prophylaxis
 Pointers
 A 7 year old male with a rash was seen in the Emergency
room and was diagnosed with a single-stranded Togavirus
from direct PCR of nasopharyngeal swabs. The ER resident
who examined the child is 2 weeks pregnant. What should
she be concerned of?
A. She will get a similar rash
B. She will have lymphadenopathy
C. Her joints will hurt
D. Her baby will have congenital malformations
E. She should worry after she goes for her first prenatal
check-up
 Causes: Single stranded Togavirus
 Transmission: Respiratory droplets
 Incubation period: 14-23 days
 Pathophysiology:
Nasopharynx   Reticuloendothelial system
Viral particles deposit in skin, synovium, CNS and
placenta
PRODROME (1-5 days)
Malaise
Fever (low-high grade)
Anorexia
Rhinorrhea
Headaches (in older children)
Conjunctivitis
+/- Lymphadenopathy
 No work-up is necessary in otherwise healthy children
 Pregnant women: MUST determine immune status.
 First 2 months of life.
 Risk increases even more up to 5 months of life.
 Risk increases towards the final trimester
 Serum IgM to Rubella is useful in newborns suspected
of having congenital rubella syndrome
 Arthropathies of the fingers
 Thrombocytopenia (rare)
 Congenital Rubella Syndrome
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IUGR
CHD (PDA, PPAS)
Hearing defects
Glaucoma, Cataracts
Neonatal purpura (“blueberry muffin rash”)
Hepatomegaly and Jaundice
Meningitis and Encephalitis
“Celery-stalking” lesions on long bones
 Treatment: Supportive
 MMR vaccines for children at 12 months and school
age
 DO NOT VACCINATE NON-IMMUNE PREGNANT
WOMEN (MMR is a live vaccine)
 Single Stranded Togavirus
 2-3 weeks incubation period
 First and last trimester of pregnancy  high risk of
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CRS
Characteristic rash + Lymph nodes
Forchheimer spots
MMR at 12 months and 4-6 years
Know about Congenital Rubella Syndrome
A 21 year old fertile female caught measles for the first time,
cause she was unvaccinated as a child. The virus ran it’s
course with no complications. It’s now 1 week after the rash
disappeared. She is not pregnant now, but she plans to be in
the next 4-5 months. What’s a girl to do ?
A. She should start taking multivitamins and folic acid
B. She should receive IVIG as soon as possible
C. She should be reassured only
D. She should see her obstetrician ASAP
E. She should have herself tested for measles antibodies
 Cause: Rubeola virus (Morbillivirus) family of
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Paramyxoviridae
Appears late winter to spring
Incubation: 7-14 days
Transmission: Droplets
Patient is contagious 4 days before the exanthem and 4
days after it’s disappearance
Pathophysiology:
Delayed type hypersensitivity
IL-12 response
Other infections
PRODROME (up to 7 days):
High fevers (>38.0C)
Malaise
3 “C’s” of Measles
Photophobia and Edema of the eyelids
Myalgias
 Usually unnecessary
 Suspected cases should be reported to the DOH
 Atypical presentations:
 Measles IgM  peaks by day 3 of the rash and still
seropositive 4-11 days after that
 Meases IgG  may indicate immunity; stays positive
after exposure/vaccination. Useful in SSPE and for
screening purposes
 High risk to develop Otitis Media, Pneumonia, Croup
and reactivation of latent TB (immunosuppression)
 Encephalitis may ensue as a result of
immunosuppression
 Subacute Sclerosing Panecephalitis SSPE
 For uncomplicated cases, treatment is generally
supportive with attention to hydration
 Vitamin A Supplementation
 MMR vaccine at 12 months of age + 4-6 years of age
 Post-exposure prophylaxis:
 Unvaccinated
 Within 3 days of exposure
 Ribavirin  immunocompromised patients or in the
setting of SSPE
 Human IVIG
 Consider IVIG in the following situations:
 Immunosuppressed individuals (ex. Chronic systemic
glucocorticoids, HIV)
 Children < 6 months to a year (especially if mom is not
immune)
 Pregnant women (since vaccine will be contraindicated)
 Usually a benign condition with a classic clinical
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course
Know the typical course
Contagious 4 days before and 4 days after the rash
Complications increase in immunocompromised
people
SSPE
Vitamin A supplementation
MMR 3 days after exposure
IVIG
A child was brought to the emergency department for a
simple febrile seizure. He was discharged and three days
later, he had a rash which appeared to be roseola
infantum. How old is this child?
A. 1 month old
B. 10 months old
C. 2 years old
D. 7 years old
E. 15 years old
 Cause: Human Herpes Virus 6a, 6b and 7
 Peak onset: 9-12 months
 Route: Saliva
 Pathophysiology:
 Remains in lymphocytes and monocytes  cytopathic
changes
 Diminished regulation of the host immune system
Previously healthy child
Abrupt onset of high fevers (usually 40 C)
Febrile seizures (15%)
 Diagnosis is clinical; work-up is not necessary
 Consider work-up only in immunocompromised hosts
 Treatment is mainly supportive, ensuring adequate
hydration
 Dehydration is the most common reason for
admission; complex febrile seizures may also be
another.
 Isolation is not necessary
 No prophylaxis necessary for close contacts
 Self-limiting condition
 Fever  Rash clinical course
 Nagayama’s spots
 HHV6B  most common etiology in children
 Isolation not necessary
 A four year old girl with HIV was seen in the ED because
she was exposed to a boy in daycare who had vesicular
lesions suspicious for chicken pox. Because she had HIV
borderline CD4 counts, the parents were worried that she
may obtain a catastrophic form of chicken pox. What
should be done?
A. Obtain titers of Varicella antibodies
B. Vaccinate her immediately
C. Passive immunization within 96 hours
D. Reassurance. It’s ok for her to get the disease and get it
over with
E. Give her a bath with betadine so she does not develop
lesions
 Cause: VZV (Herpesviridae)
 Transmission: Respiratory droplets, direct contact to
skin lesions
 Incubation: 10-21 days
 Contagious Period: 1-2 days before the onset of the
rash and 5-6 days after (until lesions “crust”)
 Pathophysiology:
 2-4 days: Virus replicates in the lymph nodes
 4-6 days: Primary viremia (RES)
 7 days: Secondary viremia
PRODROME (up to 4 days)
Fever
Abdominal Pain
Headache
Cough and Respiratory Distress **
 Not necessary, diagnosis is generally clinical in
straightforward cases
 Blood counts may show leukopenia in the first 3 days
 LFT’s show elevated ALT
 For unclear cases, a Tzanck smear may be done
 Secondary bacterial infections
 Acute Postinfectious Cerebellar Ataxia
 Varicella pneumonia  3-4 days
 Encephalitis
 Hepatitis, eye disorders, HSP, myocarditis, GN,
appendicitis and Pancreatitis
 Neonatal Varicella
 Reye’s Syndrome
 Mainly supportive; maintain adequate hydration;
break the itch-scratch cycle
 Acyclovir
 Reserved for immunocompromised patients
 Treatment for Varicella pneumonia and Encephalitis
 Treatment of Neonatal Varicella
 Oral forms  may be considered in primary infection of
adolescents
 Varicella Deterrence
 Varicella Vaccine
 PEP: Given within 36-72 hours of exposure
 Recommended in children 12 months of age; booster at
school age
 IM VZIG post-exposure prohylaxis
 Should be considered for the following:
 Newborns who are at increased risk
 Leukemia/Lymphoma
 HIV
 Immunosuppressed patients on Steroids
 Pregnant women
 Characteristic pattern of the rash
 Common complications of chicken pox
 Contagious 1-2 days before the rash until all lesions
“crust”
 Humoral + Cellular immunity  Lifelong immunity
 Indications for pre-exposure and post-exposure
prophylaxis
 Breakthrough varicella ~42 days from vaccination
 A child was seen in clinic and diagnosed with “fifth’s
disease”. He has the classic rash on the face and a lacy
rash on the arms for 3 days now. What anticipatory
guidance should be given?
A. Keep the child away from sun and heat exposure
B. Patient may go to daycare
C. Patient should wear loose fitting clothes and apply
petroleum jelly on the face
D. Clothes should be washed in hot water
E. Child should be admitted for IVIG
 Cause: Parvovirus B19
 Transmission: Respiratory droplets, fomites, blood
transfusions & transplacentally
 Incubation: 7-10 days (but up to 21 days)
 Pathophysiology:
Skin
Joints
Erythroid Progenitor cells
PRODROME (2-3 days)
Headaches
Fever
Sore Throat
Pruritus
Cough
Coryza
Abdominal Pain
 Diagnosis is often made clinical
 Patients with a history of anemia or leukemia - CBC
 Bone marrow suppression
 Arthritis
 Hydrops Fetalis
 Severe Aplastic Anemia
 Generally supportive; Pay attention to hydration
 Indication for IVIG
 Aplastic Crisis
 Consider in immunosuppressed patients – consult with
ID first
 Vaccine
 Parvovirus B19 is the only Parvovirus that causes
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human disease
Affinity and cytotoxic to erythroid progenitors  bone
marrow suppression/aplastic anemia
10% have Arthritis and arthralgias
3 phases of exanthem
No longer infectious when rash appears
IVIG only for aplastic crisis/immunocompromised
A previously healthy 3 year old male was seen in the ER
for fever and sore throat. He was diagnosed with Hand
Foot and Mouth disease. Mom wants to know how he
got the infection. Which of the following is NOT a
means of transmission for coxsackievirus?
A. Feco-oral route
B. Oral secretions
C. Respiratory droplets
D. Skin to skin contact
E. Daycare attendance
 Causes: Picornaviridae
 Coxsackievirus A16/A5/A/9/A10/B2/B5
 Enterovirus 71  Neurologic Involvement
 Incubation: 7 days
 Summer months
 Transmission: Feco-oral, Salivary, skin contact
 Pathophysiology:
virus
cell
Sore Throat
High Fevers
+/- Vomiting
Malaise
 No work-up necessary not unless patient has
neurologic manifestations
 CSF samples may be needed for neurologically
symptomatic patients
 For infections with coxsackievirus, generally none
 Myocarditis
 Enterovirus 71
 Aseptic meningitis
 Encephalitis and encephalomyelitis
 Cerebellar ataxia
 Acute Transverse Myelitis
 Guillaine-Barre Syndrome
 Opsoclonus-Myoclonus Syndrome
 Mainly supportive
 Pay attention to child’s hydration
 Cold liquids
 Avoid spicy/sour foods
 Systemic and topical analgesia
 Magic mouthwash
 NSAIDS
 Avoid Aspirin
 Deter by appropriate oral hygiene and hand washing
 Coxsackievirus and Enterovirus  Type A16 is the
most common!
 Routes of transmission
 Herpangina vs HFMD
A 15 year old male was determined to have pityriasis
rosea by his PMD. Patient has been tried on topical
steroids which did not provide relief of symptoms. The
rash is now becoming vesicular. What should be
advised?
A. Refer to Dermatology for topical retinoids
B. Refer to Dermatology for UV therapy at 80% of the
dose
C. Refer to Dermatology for laser treatments
D. Refer to Dermatology for Dapsone treatments
E. Trial of oral acyclovir
 Causes: Any virus; HHV-7?
 Usually in the Spring  Fall
 Transmission: Close contacts
 Photosensitive variant
 Localization of the exanthem
 Inverse pityriasis
 Unilateral variant
 For younger children, there is no need for work-up
 For sexually active teenagers, r/o syphillis and HIV
 “Prozone” Phenomenon
 Generally none
 Pityriasis Lichenoides Chronica
 >3 months without resolve
 Risk of miscarriage
 Mothers who develop it within the first 15 weeks of
pregnancy.
 Relief of pruritus
 Judicious use of topical steroids
 Oatmeal baths
 Anti-pruritic lotions
 Ultraviolet light (UV-B) at 80% of the erythrogenic
dose may be considered for chronic cases
 If there are vesicles, Dapsone may be considered
 Caused by many viruses
 Herald patch  mutliple macules and patches with
Christmas tree appearance
 Always rule out HIV and syphilis if clinically indicated
 Treat by itch relief. Steroid responsive
A 10 year old male with terrible eczema was diagnosed with
vesicular rashes over the areas of eczema around the eyes,
the lips and along the cleavage of the arms and legs. He
refused to eat or drink anything, but was not in dehydration
on exam. The PMD was concerned and sent him to the ED.
Initial management should include the following except?
A. Ask the nurse to start IV fluids
B. Place a line and give him IV acyclovir
C. Admit and perform urinalysis and some basic labs
D. Refer to ophthalmology
E.
Perform a PCR immediately
 Causes:
 HSV-1
 HSV-2
 Coxsackievirus A16
 Vaccinia virus
 Transmission: Direct contact
 Proposed mechanism: Systemic immune defects involving
both cell-mediated and humoral immunity, as well as
impairment in cutaneous immune responses that are
interrelated with the defective mechanical barrier
properties of affected skin in person with AD.
 Viral cultures and direct observation using DFA is the
best test to use
 A Tzanck smear may also be used but this is nonspecific
 Atypical eruptions  PCR
 Bacterial cultures if superinfection is suspected
 Multisystemic viremia
 Secondary bacterial infection and sepsis
 Keratoconjunctivitis and possible blindness
 Patients with Eczema herpeticum should be admitted
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and treated with Acyclovir
Foscarnet
Trifluridine/Vidabarin – eye drops
Valacyclovir
No vaccine available for HSV
You are seeing a 1 year old girl who recently immigrated. She
is new to your practice at 2021 GC. You give her MMR and
Varicella vaccines in your clinic to update her vaccine. Three
days later, she comes in as a sick visit with a rash on the face
and arms with relative sparing of the trunk. Dr. Cochran
diagnoses her with Giannotti-Crosti Syndrome. What is the
treatment?
A. Prescribe hydrocortisone and benadryl gel and she
should see you in two weeks.
B. Prescribe diphenhydramine PRN and ask the patient to
follow up in 2 weeks
C. Oral prednisolone at 2 mg/kg/day for 5 days
D. Admit to the hospital for IVIG
E. Refer to Dr. Purice or Dr. Ledesma
 Infantile Papular Acrodermatitis
 Papular Acrodermatitis of Childhood
 Causes: Different kinds of viruses; Hepa B? EBV?
Immunizations
 Pathophysiology:
 Local Type IV hypersensitivity reaction
 Often unecessary
 Consider a biopsy if diagnosis is unclear
 Transaminitis may be found: HBV? EBV?
 DFA and electron microscopy may fail to produce
answers
 Reassure parents
 Rash stays for 2-4 weeks
and can last up to 4
months
 Anti-pruritics
 Steroids?
 Antihistamines?
 Consults:
 Dermatology
 Gastroenterology
 Truncal sparing
 May mimic other disease like zinc deficiency
 History of acute infection with EBV or HBV
 Post immunization
 Face, buttocks, and extremities
 No treatment necessary
 Infectious Mononucleosis
 Adenovirus Infection
 Papular Purpuric Glove Socks Syndrome
 Unilateral Laterothoracic Exanthem (Assymetric
Periflexural Exanthem)
 Filatov-Duke’s Disease
 First Disease?
 Second Disease?
 Third Disease?
 Fourth Disease?
 Fifth Disease?
 Sixth Disease?
 Egg!
FEED ME…