Download CASE 5: “RASH JUDGMENT”

CASE 5:
“RASH JUDGMENT”
Questions to be answered
1.
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7.
How are rashes classified?
What infectious conditions are to be entertained in
Michelle’s case?
Are there non-infectious conditions that may present
with rashes?
In view of the general presentation, what is the most
likely diagnosis of Michelle’s case?
Discuss the possible complications of her condition
Discuss the treatment of Michelle’s case
Discuss the measure/s necessary to prevent infection
with the viral exanthems that present with
maculopapular rash
“RASH JUDGMENT”
• Michelle is a 10-year old girl with fever for the
last five days. Associated symptoms include
brassy cough and coryza, watery diarrhea and
decreased appetite. Two days later, she was
noted to have “sore eyes” and irritability.
• The mother could not recall the child’s
immunizations except that she was given the
last vaccines at the health center at age 4
months
“RASH JUDGMENT”
• On examination, she looked tired and ill, and
had a temperature of 390C; CR 88/min. and RR
26/min.. She had a rash that started 8 – 12 hrs.
earlier behind the ears and on the face then
spread down the body. The rash was
erythematous with fine macules and papules.
Conjunctivitis was prominent. On examination of
the buccal mucosa, small 1-mm.white papules
were seen opposite the 2nd molars.
“RASH JUDGMENT”
• 2 days later, the white spots disappeared
and the palms and soles were involved in
the erythematous rash which later became
brownish. This was later followed by a fine
branny desquamation first occurring in the
face later involving the body.
Q1:
How are rashes classified ?
(judged)
RASH JUDGMENT
• A exanthem is a skin eruption occurring
as an integral part of an infectious
disease. The corresponding changes in
the mucous membranes is an enanthem
• Accurate diagnosis not always possible on
preliminary examination- judgment should
be deferred until rash develops
Morphologic types or
Components of a rash
• Macule is a circumscribed
discoloration of the skin.
Often evolve into papules.
Papules are small nodular
elevations of the skin
• Vesicles are small blisters
containing clear fluid.
Pustules are small
elevations of the skin
containing pus
Maculopapular rash
Vesiculopustular rash
Morphologic types or
Components of a rash
• Petechiae are small
hemorrhages beneath
the epidermis.
Ecchymoses are
larger areas of
hemorrhage
Color Atlas of Infectious Diseases,
Emond & Rowland
Other components
• Crust/scab – congealed exudate on the
skin
• Wheal – localised effusion of fluid into the
skin causing a raised, white or pinkishwhite zone with a halo of erythema
• Erythema – a diffuse or localised red ness
of the skin
Vital information necessary in the
diagnosis of exanthematous illnesses
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Exposure
Season
Incubation period
Age
Previous exanthem
Relation of rash to
fever
Adenopathy
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Type of rash
Distribution of rash
Progression of rash
Exanthems
Other associated
symptoms or
Prodrome
Laboratory tests
Feigin and Cherry Textbook of Pediatric Infectious Diseases
Basis for Rash Judgment:
1. Prodromal period
2. Rash
3. Presence of pathognomonic or other
diagnostic signs
4. Laboratory diagnostic tests
Q2:
What infectious conditions are
to be entertained in Michelle’s
case?
Conditions that present with
Maculopapular rash
1. Measles
• Prodromal period:
– The rash is preceded by a 3 or 4
day period of fever,
conjunctivitis, coryza and cough
• Rash:
– reddish brown, appears on the
face first and progresses
downward to involve the trunk
and extremities in sequence
Measles
• Rash (cont.): The
eruption fades by the 5th
or 6th day with brownish
staining first followed by
branny desquamation.
The hands and feet do
not desquamate
Brownish discoloration
Measles
• Pathognomonic sign: Koplik’s
spots
– Detected on the mucosa of the
cheeks opposite the molars,
where they resemble coarse
grains of salt on the surface of
the inflamed membrane.
• Histologically are small
necrotic patches in basal
layers of the mucosa with
serum exudation and
mononuclear cell infiltration
Measles course
Conditions that present with
Maculopapular rash
2. Rubella (Postnatal)
• Prodromal period:
– In children there are no
prodromal period. The
appearance of the rash and
preceding lymphadenopathy
may be the first obvious sign of
disease.
– Adults and adolescents may
have a variable period of
malaise and low-grade fever
before the rash appears
Rubella rash
Rubella course
Postnatal Rubella
• Rash:
– Not distinctive; initially
discrete, delicate pink
macules beginning on face
and neck and progresses
downward to the trunk &
extremities more rapidly than
measles. On the third day the
face is usually clear
– Does not desquamate
Postnatal Rubella
• Forchheimer spots –
red spots are often
seen on the palate
– Exceptionally profuse
in this patient
Rubella
• Diagnostic sign:
– lymphadenopathy (particularly postauricular
and occipital) is a common manifestation, but
it also occurs in other diseases
• Laboratory diagnosis:
– positive throat culture for rubella virus and rise
in antibody level are helpful diagnostic aids
Congenital Rubella Syndrome
• “Blueberry muffin”
rash: a purpuric rash
may present at birth
or develop within 48
hrs.
• May be accompanied
by bleeding from the
mucosal surface
Conditions that present with
Maculopapular rash
3. Roseola infantum
• Prodromal period:
– a 3 or 4 day period of
high fever and irritability
precedes the rash which
appears as the
temperature falls to
normal
Roseola infantum (HHV 6)
• Rash:
– typically discrete rose-red
maculopapules that
frequently appear on the
chest and trunk first and
then spread to involve the
face and extremities.
– The eruption usually
disappears within 2 days.
Occasionally within several
hours
Roseola infantum
• Diagnostic sign:
– The coincidental appearance of the rash with
defervescence in an infant is distinctive
• Laboratory diagnostic test:
– none locally commercially available
Conditions that present with
Maculopapular rash
4. Erythema infectiosum:
 Rash: erupts in 3 stages
1. Red, flushed cheeks with
circumoral pallor (“slapped
check” appearance)
2. Maculopapular eruption over
upper and lower extremities
(the rash assumes a lacelike
appearance as it fades)
Erythema infectiosum
Lacelike pattern
of rash
Slapped-face appearance
Erythema infectiosum
•
Rash (cont.)
3. An evanescent stage characterized by subsidence of
the eruption followed by recurrence precipitated by
a variety of skin irritants
•
Diagnostic sign:
–
•
suggested by the slapped-face appearance in a well
child
Laboratory diagnosis:
–
future serologic tests to confirm parvovirus B19
Conditions that present with
Maculopapular rash
5. Infectious
mononucleosis
• Rash – pinkish
maculopapular, often
mistaken for rubella
– Tends to be patchy and
heavier on the limbs
Infectious mononucleosis
• Diagnostic signs:
– a triad of membranous tonsillitis,
lymphadenopathy and
splenomegaly suggests this
• Laboratory diagnostic test:
– blood smear positive for abnormal
lymphocytes.
– Monospot test and heterophil
agglutination (Paul-Bunnell) test are
positive
Infectious mononucleosis
• Hoagland’s sign: lid
edema
6. Enteroviral Infections
• Prodrome:
– Echovirus 16 (Boston
exanthem) prodrome resemble
exanthem subitum but fever
lower
– Fever & constitutional
symptoms in Echovirus 4, 6 &
9 may precede but usually
coincide with rash appearance
ECHOvirus type 19 infection
• Rash:
– May be maculopapular,
petechial and vesicular
eruptions with Coxsackie A9,
A16,A10, A5,B3 and B5
Cochsackievirus infection
7. Mucocutaneous Lymph Node
Syndrome (Kawasaki disease)
• Prodrome:
– A nonspecific febrile illness
with sore throat precedes
the rash by 2 – 5 days
• Rash:
– Generalized,
erythematous,
maculopapular. The palms
and soles are swollen and
reddened, eventually
peeling after several days
or weeks.
Mucocutaneous Lymph Node
Syndrome (Kawasaki disease)
• Rash (cont.)
– Dryness with erythema
of the lips (red
strawberry tongue),
mouth and tongue
accompanies bilateral
conjunctival injection
Mucocutaneous Lymph Node
Syndrome (Kawasaki disease)
• Conjunctivitis
– Bilateral, bulbar,
generally nonpurulent
• Cervical
lymphadenopathy
– Usually unilateral
– Not explained by other
known disease
process
Mucocutaneous Lymph Node
Syndrome (Kawasaki disease
• Periungual
desquamation or
• Perianal
desquamation may
follow in the subacute
phase
Diagnostic Criteria for Kawasaki
Disease
•
•
Fever lasting for at least 5 days
Presence of at least 4 of the ff. 5 signs:
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–
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–
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Bilateral bulbar conjunctival injection, generally nonpurulent
Changes in the mucosa of the oropharynx, including injected
pharynx, injected and/or dry fissured lips, strawberry tongue
Changes of the peripheral extremities, such as edema and/or
erythema of the hands or feet in the acute phase; or periungual
desquamation in the subacute phase
Rash, primarily truncal; polymorphous or nonvesicular
Cervical adenopathy, > 1.5 cm., usually unilateral
lymphadenopathy illness not explained by other known disease
process
8. Staphylococcal Scalded Skin
Syndrome
• Prodrome:
– None
– Fever and irritability occur
at the time of onset of the
rash
• Rash:
– Generalized,
erythematous,
scarlatiniform eruption with
sandpaper-like texture
Staphylococcal Scalded Skin
Syndrome
• Rash (cont)
– The erythema is
accentuated in the skin
folds.
– The skin is tender and
within 1-2 days, bullae
appear and the epidermis
separate into large sheets,
revealing a moist, red,
shiny surface underneath
(Nikolsky sign)
Ritter’s disease
Staphylococcal Scalded Skin
Syndrome variants
+ Nikolsky sign
Lyell’s disease
Lyell’s disease
Toxic Epidermal Necrolysis
Staphylococcal Scalded Skin
Syndrome variants
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Newborns – Ritters disease or
Pemphigus neonatorum
Older children and adults – Lyell’s
disease or Toxic Epidermal
Necrolysis
– TEN differentiated from SSS
by intraepithelial splitting at
the dermoepidermal junction
– TEN usually drug-induced
from phenytoin,
phenobarbital,
sulfonamides,
penicillin
Toxic epidermal Necrolysis
Staphylococcal Scalded Skin
Syndrome variants
• Diagnostic sign:
– An associated staphylococcal infection e.g.
Impetigo or purulent conjunctivitis may be
present
• Laboratory diagnostic tests:
– Culture of skin positive for phage group II
9. Staphylococcal Toxic Shock
Syndrome
• Prodrome:
– High fever, headache
confusion, sore throat,
vomiting, diarrhea and shock
may precede or may be
associated with the rash
• Rash
– There are no characteristic
features of the rash
– Occurs most prominently in the
trunk & extremities
– Associated with edema and
desquamation
Poor capillary refill in TSS
Staphylococcal Toxic Shock
Syndrome
• Diagnostic signs:
– The scarlatiniform eruption is associated with
high fever, toxicity and a shock-like state
• Laboratory tests:
– Cultures of various mucosal surfaces or
purulent lesions should be positive for
Staphylococcus aureus
10. Typhoid fever
• Rash:
– Rose spot
• Typically appear towards the end
of the 1st week
• Present in 50% of adults but less
common in children
• Difficult to detect on dark skin
• Districuted over abdomen, chest
and back but rarely seen in face,
hands or feet
– Step-ladder temperature chart
Q3:
Are there non-infectious
conditions that may present
with rashes?
Noninfectious conditions
• Drug eruptions/toxic erythemas
• Sunburn
• Miliaria
– No prodromal periods
– Sunburn rashes confined to the areas not protected
by clothing
– Miliaria: fine punctiform lesions are chiefly confined to
the flexor areas. Rash not usually generalized and
does not desquamate
Drug Eruptions…Others
Erythema
multiforme
from
sulphonamide
Urticaria
caused by
Penicillin
Malar “butterfly
Rash” of Systemic
Lupus erythematosus
Q4:
In view of the general
presentation, what is the
most likely diagnosis of
Michelle’s case?
Task 5:
Discuss the possible
complications of her condition
Task 6:
Discuss the treatment of
Michelle’s case
Task 7:
Discuss the measure/s
necessary to prevent infection
with the viral exanthems that
present with maculopapular
Task 8:
Enumerate possible
Key Learning
points in
Michelle’s case
CASE 5:
“RASH JUDGMENT”