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EXANTHEMS
Patricia A. Treadwell, M.D.
Professor of Pediatrics
Indiana University School of Medicine
FACULTY DISCLOSURE
 I have the following financial relationships with
the manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed
in this CME activity.
:Investigator- Novartis
 I do intend to discuss an unapproved/investigative
use of a commercial product/device in my
presentation.
i
HAND-FOOT-AND-MOUTH
DISEASE
 HFMD
 Usually occurs in children less than 10
years off age
 Fever
HFMD





Classically Coxsackie virus A16
Human Enterovirus 71
Coxsackie virus A10,
A10 or A5
Other Coxsackie viruses
T i ll incubation
Typically
i b ti is
i 3-6
3 6 ddays
Dyer JA. Pediatr Ann 2007;36:21-29.
HFMD - exanthem
 Vesicular eruption
 Lesions often on lateral fingers and toeswith
i h an elliptical
lli i l shape
h
 Erythematous surround
 May be particularly localized to areas of
inflammation
HFMD - enanthem
 Vesicles in the oral cavity rupture to
become ulcers
 Most
M commonly
l on the
h llaterall aspects off
the tongue
HFMD - treatment
 Encourage fluid intake
 Fever control
 Analgesics
VARICELLA
 Varicella-Zoster
Varicella Zoster virus
 Prodrome of fever, headache and malaise
 Highly contagious
 Incubation 10-21 day
y range
g
VARICELLA - exanthem
 Tear drop shaped vesicles on an
erythematous base
 “Dew-drop
“D d
on a rose petal”
l”
 The lesions spread from the trunk to the
extremities
 Lesions p
progress
g
to pustules
p
and later
crusted lesions
VARICELLA - enanthem
 Vesicular lesions occur which may become
pustular
 Vesicles
V i l which
hi h rupture may become
b
ulcers
l
VARICELLA - treatment





Monitor fluid intake
Reduce fever
Antihistamines
Antivirals especially if immunocompromised
Role of vaccine to pprevent disease
Mann M, et al: Pediatrics 2008;122:e744-751.
SCARLET FEVER
 Streptococcus pyogenes
 Erythrogenic toxin
 Pharyngitis and eruption
 Fever
 Incubation 2-5 days
SCARLET FEVER - exanthem
 Erythema accentuated in fold areas
 Pastia’s sign
 “Sand-paper” type eruption
 Desquamation
q
SCARLET FEVER - enanthem
 Erythematous oropharynx
 Exudates
 (Cervical lymphadenopathy)
 Petechiae of soft palate
p
 Strawberry tongue
SCARLET FEVER - treatment
 Monitor fluid intake
 Reduce fever
 Analgesics
 Penicillin
 Clindamycin
 Erythromycin
UNILATERAL
LATEROTHORACIC EXANTHEM
 Unilateral laterothoracic exanthem
 A.K.A. Asymmetrical periflexural
exanthem
h off childhood
hildh d
 Described in 1962
 Usually in children, reports in adults are
rare
UNILATERAL
LATEROTHORACIC EXANTHEM
 Eczematous papules of unilateral axilla and
flank
 Then
Th spreadd to other
h areas off body
b d
 Unusual viral exanthem-reported associated
with parvovirus B19 and Epstein Barr virus
along with others
UNILATERAL
LATEROTHORACIC EXANTHEM
 Topical corticosteroids for inflammation
 Antipruritics for itching
REFERENCES
 Chuh AA
AA, et al: Unilateral mediothoracic
exanthem: a variant of unilaterothoracic
exanthem Cutis 2006;77:29-32.
exanthem.
2006;77:29 32
 Scheinfeld N: Unilateral laterothoracic
exanthema
h
with
i h coincident
i id evidence
id
off
Epstein Barr virus reactivation: Exploration
off a possible
ibl link.
li k Dermatol
D
l Online
O li J
2007;13:13.
GIANOTTI CROSTI SYNDROME
GIANOTTI-CROSTI
 Associated with viral illness
 Virus-associated exanthem
 Most often in children aged 2-6 years of
age
 Generalized lymphadenopathy may be seen
 Infrequently pruritic
 May last 6-8 weeks
GIANOTTI CROSTI SYNDROME
GIANOTTI-CROSTI
 Clinical findings:
-Papular lesions
Urticarial lesions
-Urticarial
-Less often, vesicular or papulovesicular
-More concentrated on the arms and
legs
-Can be seen on the trunk, but less
dense
-Koebner phenomenon
GIANOTTI CROSTI SYNDROME
GIANOTTI-CROSTI
 Viruses associated with Gianotti-Crosti
Gianotti Crosti
-Epstein-Barr
-Hepatitis
Hepatitis A,C
AC
-Cytomegalovirus
-Human
Human herpesvirus 6
-Coxsackievirus A16,B4, B5
-Rotavirus
Rotavirus
-Parvovirus B19
GIANOTTI CROSTI SYNDROME
GIANOTTI-CROSTI
 Viruses associated with Gianotti-Crosti
Gianotti Crosti
syndrome-continued
-RSV
RSV
-Echovirus
-Enterovirus
Enterovirus
-Rubella and Mumps virus
-Parainfluenza
Parainfluenza virus
-HIV
GIANOTTI CROSTI SYNDROME
GIANOTTI-CROSTI
 Bacteria associated with Gianotti-Crosti
Gianotti Crosti syndrome
-Bartonella henselae
-Beta-hemolytic streptococci
-Borrelia Burgdorferi
-Mycoplasma
y p
pneumoniae
p
 Gianotti-Crosti syndrome has been reported
follwing some immunizations, however is not a
contraindication to giving those immunizations
GIANOTTI-CROSTI SYNDROME
-Treatment
Treatment
 Topical corticosteroids (one report of
worsening- does not pose a
contraindication)
 Oral antihistamines if patient has pruritus.
GIANOTTI-CROSTI SYNDROMEReferences
 Fastenberg M,
M et al: Acral Papules:
Gianotti-Crosti Syndrome. Pediatr Ann
2007;36:800 804
2007;36:800-804.
 Xia Y, et al: Pruritic Acral Rash in a Child.
Gi
Gianotti-Crosti
iC
i Syndrome.
S d
A Fam
Am
F
Physician 2008;78:103-105.
MEASLES (RUBEOLA)




Caused by a paramyxovirus,
paramyxovirus an RNA virus
Highly contagious prior to the use of the vaccine
Uncommon with widespread use of the vaccine
Prodrome of cough, coryza, conjunctivitis and
Koplik’ss spots
Koplik
 Fever
 Incubation 10-14
10 14 days
MEASLES - exanthem
 A maculopapular eruption beginning at the
scalp line->hairline->forehead->
retroauricular >face neck->then
retroauricular->face,
neck >then spreading
downward
 Fades
F d over a 72 hhour period
i d
 Brownish discoloration noted after fading
MEASLES - enanthem
 Koplik
Koplik’ss spots
-white or bluish-gray specks
-1
1 mm in size
-typically on buccal mucosa opposite
lower molars
 May see erythematous papules on the palate
 Posterior pharynx often erythematous
MEASLES - treatment
 Monitor fluid intake
 Monitor respiratory status
 Reduce
R d
fever
f
 Vitamin A in children 6 months to 2 years
and
d those
th
who
h have
h
an immunodeficiency
i
d fi i
2006 Red Book. AAP Committee on Infectious Disease
INFECTIOUS MONONUCLEOSIS
 Epstein-Barr
Epstein Barr virus
 Prodrome of headache, malaise, fever and
pharyngitis
h
ii
 Incubation 33-49 days
 Exanthem occurs in 35% patients
 Accompanying Strep pharyngitis in 20
20-25%
25%
INFECTIOUS
MONONUCLEOSIS - exanthem
e anthem





Erythematous maculopapular lesions
Initially on the trunk and then spreads
Areas of confluence can occur
Pruritus
F d iin 33-44 days
Fades
d
Ellen Rimsza, M, et al: Pediatr Clin North Am 2005;52:9-24.
INFECTIOUS
MONONUCLEOSIS - enanthem
 Macules or petechiae of the palate
 Erythema of the oropharynx
 Findings of Strep pharyngitis when present
INFECTIOUS
MONONUCLEOSIS - treatment
 Monitor fluid intake
 Reduce fever
 Analgesics
 If Strep
p pharyngitis
p y g is present,
p
,
treat with appropriate antibiotics
ROCKY MOUNTAIN
SPOTTED FEVER
 Caused
Ca sed by
b Rickettsia
Ri k tt i rickettsii
i k tt ii
 Typically history of tick exposure
 Incubation 2-14 days
ROCKY MOUNTAIN
SPOTTED FEVER
 Fever
 Severe headache
 Confusion
 Nausea and vomiting
g
 Photophobia
ROCKY MOUNTAIN
SPOTTED FEVER - exanthem
 Exanthem present in 90 % patients
 Erythematous macules and papules initially
 Later, petechial or purpuric lesions
 Lesions occur initially
y on the palms
p
and
soles, then spread centrally
ROCKY MOUNTAIN
SPOTTED FEVER
 Supportive therapy may be necessary
 Doxycycline
 Chloramphenicol
ROCKY MOUNTAIN SPOTTED
FEVER References
FEVER-References
 Chen LF
LF, et al: What
What’ss New in Rocky
Mountain Spotted Fever? Infect Dis Clin
North Am 2008;22:415-432.
2008;22:415 432
 Flicek BF. Rickettsial and Other TickB
Borne
Infections.
I f i
C i Care
Crit
C
Nurs
N
Clin
Cli
North Am 2007;19:27-38.