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Pediatric Exanthems Continuity Objectives • • • Be familiar with the terminology to describe rashes accurately to other providers Be able to identify the rashes of Measles, Rubella, Scarlet Fever, Erythema Infectiousum, and Roseola Infantum Know the general clinical features of each of the above rashes Continuity Review of Terminology of Skin Lesions Continuity The Basics of Rashes • Distribution – Localized vs. Systemic – Sun exposed areas? • Configuration – Round – Serpiginous – Coalesce • Description – Macular, Papular, Petechial • Evolution – Where it began and where it ended • Associated Findings Continuity Description of Rashes • Macule – circumscribed color change in the skin that is flat • Papule – solid, elevated area < 1 cm in diameter • Plaque – solid, circumscribed area >1 cm in diameter • Vesicle – circumscribed, elevated < 1 cm with serous fluid • Bulla – circumscribed, elevated > 1 cm with serous fluid • Pustule – vesicle with purulent material • Nodule – mass with indistinct borders, elevates over epidermis • Wheal – circumscribed, flat topped, firm elevation of skin resulting from tense edema of papillary dermis Continuity Description of Rashes MACULE VESICLE Continuity PUSTULE NODULE Definitions • Exanthem – a skin eruption occurring as a symptom of a general disease • Enanthem – eruptive lesions on the mucous membranes Continuity Classic Childhood Exanthems 1. 2. 3. 4. 5. 6. Measles (Rubeola) Scarlet Fever Rubella (German Measles) Filatow-Dukes Disease Erythem Infectiousum Roseola Infantum Continuity “1st Disease” - Measles • Paramyxovirus • At risk: – Preschool age children unvaccinated – School age children in whom vaccine failed • Season: late winter/spring • Incubation: 8-12 days • Infectious: 1-2 days before prodrome to 4 days after onset of rash Continuity Measles – clinical features • Prodrome – Day 7-11 after exposure – Fever, cough, coryza, conjunctivitis • Enanthem – Koplik’s spots appear 2 days before rash and lasts 2 days into rash Continuity Koplik’s Spots Continuity Koplik’s Spots Continuity Exanthem of Measles Continuity Exanthem of Measles Continuity Complications of Measles • • • • • Otitis Media Bronchopneumonia Encephalitis Pericarditis Subacute sclerosing panencephalitis – late sequellae due to persistent infection of the CNS Continuity “2nd Disease” - Scarlet Fever • Due to erythrogenic exotoxin-producing group A beta-hemolytic streptococci • At risk: – <10 years old – Peak 4-8 years old • Season: – late fall, winter, spring – Likely due to close contact indoors in school • Incubation period: 2-4 days • Infectious period: during acute infection, gradually diminishes over weeks Continuity Scarlet Fever – Clinical Features • Abrupt onset fever, headache, vomiting, malaise, sore throat • Enanthem – Bright red oral mucosa – Palatal petechiae – Tongue changes Continuity Strawberry Tongues Continuity Scarlet Fever - Exanthem Continuity Scarlet Fever - Exanthem Continuity Scarlet Fever - Complications • Purulent – Otitis media – Sinusitis – Peritonsillar/retropharyngeal abscesses – Cervical adenitis • Nonsuppurative sequalae – Rheumatic Fever – Acute glomerulonephritis Continuity “3rd Disease” - Rubella • • • • • Togavirus At risk: Unvaccinated adolescents Season: late winter/early spring Incubation: 14-21 days Infectious period: 5-7 days before rash to 3 to 5 days after rash Continuity Rubella – Clinical Features • Asymptomatic infection in up to 50% • Prodrome – Children: absent to mild – Adolescent & adult: fever, malaise, sore throat, nausea, anorexia, painful occipital LAD • Enanthem – Forschheimer’s spots petechiae on the hard palate Continuity Rubella - Exanthem Continuity Rubella - Exanthem Continuity Rubella - Complications • Arthralgias/arthritis in older patients • Peripheral neuritis, encephalitis, thrombocytopenic purpura (rare) • Congenital rubella syndrome – Infection during first trimester – IUGR, eye findings, deafness, cardiac defects, anemia, thrombcytopenia, skin nodules Continuity “4th Disease” – Filatow Dukes Disease • Obsolete • Probably now better defined as another clinical entity Continuity “5th Disease” – Erythema Infectiosum • • • • • Human Parvovirus B19 At risk: school age children Season: sporadic Incubation period: 4-14 days Infectious period: up until onset of the rash Continuity Erythema Infectiosum Clinical Features • Over 50% of infections are asymptomatic • Prodrome: – Mild fever (15-30%) – Sore throat – Malaise • Adults: flu like symptoms, arthralgias/arthritis, rash in up to 40% • Hematological changes: proerythrocyte tropic virus – drop in RBC count Continuity EI: Slapped Cheek Continuity EI: Exanthem Continuity EI: Exanthem Continuity EI: Complications • Immunocompromised: – Chronic infection with severe, persistent, relapsing and remitting anemia, prolonged viral shedding • Patients with decreased RBC survival time – Hemoglobinopathies, hemolytic disease – Aplastic crises – Prolonged viral shedding • Fetal infection – hydrops fetalis (1-9% risk of death) Continuity “6th Disease” – Roseola Infantum • • • • • Human Herpes Virus 6 (and 7) At risk: 6-36 months (peak 6-7 months) Season: sporadic Incubation: 9 days Infectious period: – Virus is intermittently shed into saliva throughout life; asymptomatic persistent infection Continuity Roseola – Clinical Features • High fever for 3-4 days • Abrupt defervescence with appearance of rash • Associated seizures likely due to infection of the meninges by the virus Continuity Roseola - Exanthem Continuity Roseola - Exanthem Continuity