Download Dermal manifestations in viral diseases in children

Dermal manifestations in VIRAL diseases in children
DR BINOD KUMAR SINGH
Associate Professor, NMCH, Patna
CIAP Executive Board Member 2015
NNF State President-2014
IAP State Secretary ,Bihar 2010-2011
NNF State Secretary , Bihar 2008-2009
Chief Consultant:Shiv Shishu Hospital
K- 208 P C Colony ,Hanuman Nagar,
Patna 800020.
Email- [email protected]
web site :- www.shivshishuhospital.com
IN HISTORY TAKING :
a) Exposures
- Viral diseases (home, day care…)
- Travelling history
-Pets, insects
- Medications and drugs
- Immunization
b) Features of rash
- Temporal association (onset relative to fever)
- Progression and evolution
- Location and distribution
- Pain or pruritus
• IN PHYSICAL EXAMINATION :
a) Distribution pattern
- symmetrical
- asymmetrical
b) Morphology
- monomorphic
- pleomorphic
c) Configuration
- linear,
- annular,
- grouped,
-discrete
Macule
Flat spots, not palpable
Papule
Elevated, palpable, small
rounded lesions
Vesicles
Small, fluid-filled blisters
Pustules
Small blisters containing
purulent fluid
HERPES VIRUS GROUP
• Double stranded DNA virus
• Latent but life long infection
HERPES SIMPLEX :
HSV-1:-Orolabial herpes (most prevalent)
HSV-2:-Genital herpes (after attaining sexual
activity)
OROLABIAL HERPES
• C/F:- <1 % of patient develop HERPITIC
GINGIVOSTOMATITIS(mostly are children and young adults )
• Asso with high fever, regional lymphadenopathy & malaise
• Pain, foul breath, dysphagia & pharyngitis.
• Diagnosis :- C/F –Typical vesicular lesons at the
lips
virus isolation by cell culture
PCR
• Treatment : Acyclovir 15mg/kg 5 times daily for 7 days.
• Precaution:- Sunblock should be applied.
Dental & Surgical procedures should be done
with utmost care
OROLABIAL HERPES ,TRIGGERED BY
SUNBURN
HERPETIC GINGIVOSTOMATITIS
Broken vesicles that appear as erosion or ulcers covered
with white membrane
 spreads to oral mucosa, tongue and tonsils.
HSV-1,EYELID INFECTION CAUSED BY
A KISS FROM INFECTED PERSON
HERPETIC WHITLOW
•
•
•
•
Causative organism:-HSV-1
Age:-<10 years
Thumb sucking and nail biting by infected patients.
C/F:-lesions begin with tenderness & erythema,usually
of lateral nail fold or on the palm
After 24-48 hrs- deep seated blisters develop
• Mimics cellulitis:- swelling of affected hand, lymphatic
streaking & swelling of epitrochlear& axillary LN
Caused due to finger sucking.
NEONATAL HERPES
• Causative organism:-HSV-2(70%)
HSV-1 (Contact with orolabial herpes)
• Occurrence rate:- 85% -time of delivery
10-15%-non-maternal sources after delivery
5%- inutero with intact membrane
• Inutero infection:-foetal anamolies, limb hypoplasia,
microcephaly,microphthalmus,encephalitis,chorioretinits,intra
celebral calcification.
• Prenatally acquired neonatal herpes has 3 types :A) localized infection of skin, eye or mouth(SEM)
B) CNS disease
C) Disseminated disease-encephalitis,hepatitis,pneumonia,
coagulopathy.
Limb hypoplasia with herpetic lesion
• FATAL OR PERMANENT NEUROLOGICAL SEQUELAE
• Diagnosis:-Viral culture,
DFA Staining of material from skin or ocular lesion.
• Treatment:- IV Acyclovir-60 mg/kg/day
14 days (SEM)
21days (CNS)
• PREFERRED CAESEREAN SECTION
• Scalp electrodes and Vaccum delivery should be avoided .
NEONATAL HERPES ASSOCIATED WITH SCALP ELECTRODES
VARICELLA/CHICKENPOX
•Caustative Organism: VaricellaZoster Virus
•IP:-10-21 days
•Mode of transmission:- aerosols
•Infectivity period:-From 5days before to
5days after eruption
•C/F:-Tear drop vesicles on erythematous
base (dew drop on rose petal)
Pleomorphic in nature.
Initially macules, that develop into vesicles
within 24hrs.
•Site :- trunk, face & oral mucosa
•Complications:-Sec. bacterial infection
Cerebellar ataxia & encephalitis
Reye syndrome:-hepatitis with acute
encephalopathy caused by use of aspirin &
other salicylates.
VARICELLA COMPLICATED WITH
BULLOUS IMPETIGO
• Diagnosis :- Clinical manifestation
Tzanck smear
DFA test
• Treatment :-Acyclovir 20mg/kg 4 times a day
(max. dose being 800mg)
• Prevention:- Live attenuated varicella vaccine
» 1st dose -12-15 months
2nd dose -4-6 yrs.
ZIG
CONGENITAL VARICELLA SYNDROME
• Caused by Maternal infection –
in first 20 weeks of GA
• Females are affected more
• C/F:-Hypoplastic limb –usually
unilateral and lower extremity
Cicatrical skin lesions
Ocular diseasemicrophthalmous, nystagmus,
chorioretinitis, hypoplasia&
atrophy of optic disc, congenital
cataract &Horner syndrome
CNScortical atrophy ,
ventriculomegaly, MR,
learning disabilities.
MODIFIED VARICELLA LIKE SYNDROME
• Occurs in previously
immunized patients leading
to reduced severity on
exposure to natural varicella
• C/F:-mostly macules and
papules ,with fewer
vesicles.
average no.-35-50(unlike
300)
VARICELLA IN
IMMUNOCOMPROMISED
• Severe and Fatal.
• Lesions are ulcerative,
necrotic, hyperkeratotic
.
HERPES ZOSTER/SHINGLES
• Rare below 1yr.Caused by
intrauterine VZV or VZV
exposure in 1st few yrs.
• Occurs due to reactivation of
VZV in sensory dorsal root
ganglion.
• Site:-Thoracic(55%), Cranial
(20%) ,Lumbar(15%), Sacral
(5%)
• C/F:- Pain in affected area
precede or coincide with
papule or plaque of
erythema in a dermotome,
• within hours blisters develop
Ophthalmic zoster
• Ophthalmic div. of 5th CN
• Hutchison’s sign:-external div.
of nasocilliary branch
involved leading to vesicles
on side &tip of nose
• Ocular involvement:uveitis(92%),keratitis(50%)
• Complications:- Ramsay hunt
synd-7th &8th CN involvement
• S3 orS2 involvement:-acute
urinary retention,
heamaturia & pyuria
• Treatment-Bed rest,Hot
fomentation,Acyclovir
INFECTIOUS MONONEUCLOSIS
• Causative Organism:-Epstein Barr
Virus
• Mode of transmission:-oral
secretions, orogenital sex or
hematogenous route also.
• IP:-3-7weeks
• C/F:fever,headache,lymphadenopathy,spl
enomegaly,pharyngitis
• In mucous membrane-pinhead sized
petechiae 5-20 in no.at the junc.of
soft and hard palate=FORCHHEIMER’S
SPOTS
• Treatment:-Acyclovir is ineffective.
Prednisolone can be given in pharygeal
encroachment on the airway.
INFECTIOUS MONONUCLEOSIS
GIONOTTI-CROSTI SYNDROME/PAPULAR ACRODERMATITIS OF
CHILDHOOD/PAPULOVESICULAR ACROLOCATED SYNDROME
•
Causative organism:-EBV-MC
(previously HBV) adenovirus,
CMV,enterovirus,rotavirus,Hep A
&C,Parainfluenza virus,ParvovirusB19
Immunization against :Poliovirus,diptheria,pertussis,JE,influenza,
hepB,measels.
• Age:-6mo-14 yrs
• Chuh proposed diagnostic criteria :i)monomorphous flat topped,pink
brown,papules or papulovesciles of 110mm in diameter
ii)any 3 or 4 sites involvedface,buttocks,forearms,extensor legs
iii)symmetry
iv)duration of atleast 10 days
Negative Clinical features:i)Extensive truncal lesions
ii)Scaly lesions
Mucous membrane spared.
• Treatment :- NONE .self limiting.
CYTOMEGALIC INCLUSION DISEASE
• Caustative organism:-Cytomegalo
virus
• 90% pts are asymptomatic
• C/F:-cutaneous lesions are caused by
thrombocytopenia with resultant
petechiae, purpura & ecchymoses
• Purpuric violaceous
lesions(macular,papular or
nodular)show extrameduallry
hematopoeisis(dermal
erythropoeisis)producing
“BLUEBERRY MUFFIN BABY”
• Asso. with jaundice,
hepatosplenomegaly, cerebral
calcification,choriretinitis,
microcephaly , MR,deafness.
• Treatment :-regresses in 1st 6 wks of
life so no treatment required.
ROSEOLA INFANTUM(EXANTHEM SUBITUM,6TH DISEASE)
• Causative organism:-HHV-6,
HHV-7(Human herpes virus)
• Common cause of
sudden,unexplained high fever
in young children btw 6-36
months.
• C/F:-Prodromal-high
fever,convulsions&
lymphadenopathy.
On 4th day:-fever drops &
morbilliform erythema
consisting of rose coloured
discrete macules on
neck,trunk,buttocks.
Blanchable halo around the lesion.
Mucous memb spared.
• Treatment :- complete
resolution in 1-2 days so no
treatment required.
MOLLUSCUM CONTAGIOSUM
•
Causative organism:-MCV 1-4,MCV-1-MC
in children,MCV-2-In HIV
•
Mode of transmission:-direct skin to skin
contact,spc if skin is wet
• .
• C/F:-smooth surfaced, firm,dome
shaped,pearly papules,3-5mm in diam.
“CENTRAL UMBILICATION” is characteristic.
Giant lesion=1.5 cm in diam
•
Site:-face,trunk & extremeties.
If only genital involvement is there
consider sexual abuse.
Spontaneous resolution,individual lesions
lasts 2-4mo,duration of infection is 2 yrs.
•
Treatment:-Topical Tretinoin,5% Na
nitrite+5% salicylic acid or Catharidin,
nicking ,cryotherapy, TCA(Trichloroacetic
acid)
HERPANGIA
• Causative Organism:Coxsackievirus(A8,A10&A16),Echo
virus,Enterovirus71
• C/F:-fever,headache,sore
throat,dysphagia,anorexia.
->1 or more yellowishwhite,slightly raised 2 mm
vesicles in throat,usually
surrounded by an intense
areola,seen in ant.faucial
pillars,tonsils,uvula,soft palate.
- they ulcerate,leaving a shallow
punched out grayish-yellow
crater2-4mm in diam
• Treatment:-it disappears in 510days.
Supportive treatment-Topical
Anaesthetics.
HAND FOOT MOUTH DISEASE
• Age:-2-10yrs
• C/F:-Begins with Fever,sore mouth.
• Oral lesionssmall 4-8mm,rapidly ulcerating
vesicles surrounded by red areola
on the buccal mucosa,tongue,soft
palate & gingiva.
• Hand & Foot lesions-asymptomatic
red papules that quickly become
small,gray 3-7mm vesicles
surrounded by red halo.
oval, linear or crescentric.
• Treatment:--Resolves in a week
-Oral topical anaesthetics.
MEASELS/RUBEOLA
•
•
•
•
•
Causative organism:-Paramyxovirus
Age:-mostly <15 mon.
Mode of transmission:-aerosol
IP:-9-12days
C/F:-Prodrome-fever,malaise,conjunctivitis
&upp. Resp. sympt.(nasal
congestion,sneezzing,coryza,cough)
After 1-7 days-exanthem appears usually
macular,morbilliform lesion on ant. Scalp line
&behind ears.
2nd day-trunk & extremeties
3rd – 4th day-whole body involved
6th-7th day-exanthem clears
KOPLIK’S SPOTS:-appear 1st on buccal mucosa
nearest to lower molar as 1mm white papules
on erythematous base.
• Complication:-otitis media, pneumonia,
encephalitis,thrombocytopenic purpura.
• Treatment:-Bed rest, analgesics, anti-pyretics.
Vit A reduces morbidity & mortality.
CONJUNCTIVITIS
KOPLIK SPOTS
MACULAR RASH
RUBELLA/GERMAN MEASELS
•
•
•
•
Causative Organism:-Togavirus
Mode of transmission:-aerosols
IP:-12-23 days
C/F:-Prodrome-fever,malaise,sore
throat,eye pain,headache,red
eyes,runny nose& adenopathy
Characteristic-pain on lateral & upward
eye movement.
Cut. Lesions begin on face& progress
caudal,covers the entire body in
24hrs,typically pale pink,morbilliform
macules smaller than measles.
Resolves on 3rd day.
Forchheimer’s sign:pinhead size red
macules or petechiae on soft palate &
uvula
Post.cervical, suboccipital &postauricular
lymphadenitis=>50% cases
• Diagnosis:-Rubella specific Ig M or PCR
CONGENITAL RUBELLA SYNDROME
• Infants born to mothers
infected in 1st trimester.
• C/F:-cong.catarct,cardiac
defect&deafness
Cutaneous lesion :thrombocytopenic purpura,
hyperpigmentation of navel,
forhead & cheeks,infiltrated
2-8 mm lesions(BLUEBERRY
MUFFIN TYPE) which
represent dermal
erythropoeisis,chronic
urticaria&reticulated
erythema of face &
extremities.
ASSYMETRIC PERIFLEXURAL
EXANTHEM OF CHILDHOOD/APEC
• Unilateral laterothoracic exanthem
• Causative organism:-unkown,Parvovirus
B19 is speculated
• Girls>boys
• Age:-8mo-10yrs
• Time:-late winter,early spring
• C/F:-Prodrome-URTI,GIT infect.
Cutaneous lesion:Discrete 1mm
erythematous papules, morbilliform
plaque,mild pruritis. Starts unilaterally
close to flexural area usually Axilla(75%).
Normal skin may intervene
After 5-15days:Contralateral side may get
involved(70%)
Lymphadenopathy-70%
• Treatment:-Resolves in 2-6 wks.
Oral antihistaminic for pruritis.
ERYTHEMA INFECTIOSUM/5TH DISEASE
•
•
•
•
Causative Organism:-Parvovirus
Time:-late winter,early spring
IP:-4-14days
C/F:-Prodrome-headache,runny
nose,low grade fever
• 3 phases:1st:abrupt asympt. Erythema of
cheeks called slapped
cheek(butterfly pattern)
2nd: prox. Extremities, trunk (After
1-4 days)
3rd:recurring,after exposure to
heat,bathing,sunlight or crying &
exercise
• Treatment:-Self limiting
PAPULAR PURPURIC GLOVES & SOCKS SYNDROME
• Causative organism: Parvovirus
• Age:-teenagers
• C/F:-Pruritis,oedema,erythema
of hand and feet sharply cut off
at wrist &feet.
Cheeks,elbows,knees &groin folds
may also be involved.
Oral erosions-shallow
ulceration,aphthous ulcers on
labial mucosa,erythema of
pharynx,Kopliks spot
Lips may be red &swollen.
Vulvar oedema &dysuria may also
be seen.
• Treatment :-Self limiting ,
resolves within 2 wks.
DENGUE
•
•
•
•
Causative organism:Arbovirus
Vector:-Aedes mosquitoes
IP:-2-15days
C/F:-sudden onset of high
fever,myalgia,retro-orbital
pain,severe backache(BREAKBONE
FEVER)
Cutaneous lesion-After 3 -5days of
defervescence.
Morbilliform,confluent,
characterestically small islands of
normal skin-”islands of white in sea
of red”
Facial flushing prominent.
Cutaneous hemorrhage:DHF or DSS
• Diagnosis:-Dengue specific IgM ELISA
• Treatment:-Recovery in 7-10 days.
CHIKUNGUNYA
•
•
•
•
Causative organism:-Arbovirus
Vector:-Aedes mosquitoe
IP:-2-7 days
C/F:-morbilliform ,affects arms,upper
trunk &face. Confluent & island of
sparing can be seen.
By 2nd day >1/2 of pts. are affected.
In acute illness ecchymoses can be seen.
In<1yr pt.-bullous eruption can be seen
which become hemorrhagic later.
Nikolsky sign is +ve.
Resembles TEN, more than 80% of body
surface becomes denuded.
• Diagnosis:-IgM,PCR
• Treatment:-like burn pts.
VERRUCA VULGARIS/COMMON WART
• Causative organism:-HPV-1,2,4,27,57
&63
• Age:-5-20yrs
• Risk factors:frequent immersion oh
hands in water
• Site:-finger & palms
By autoinoculation in nail biters to
tongue & lips
• Lesion:-pinpoint to >1cm,avg about
5mm,rounded papules with rough
grayish surface,grows in size for wks
to mon.,tiny black dots may be visible
representing thrombosed,dilated
capillaries.
• Treatment :-Electrodissection,
Ablative laser,Cryotherapy,keratolytic
sol. (16.7%lactic acid or salicylic acid)
VERRUCA PLANA/FLAT WARTS
• Causative organism:-HPV 3,10,28
& 41
• Age:-children & young adults
• Risk factors:-sun exposure &
swimmers
• Lesion:-2-4mm flat topped
papules,slightly erythematous
brown papule on pale skin &
hyperpigmented on darker
skin.Kobner’s pheno is seen.
• Site:-face,neck,dorsum of hands
& wrists,elbows & knees.
• Treatment:-highest rate of
spontaneous remission.
Chemical cautery or light
electrodissection is successful.
VERRUCA PLANTARIS/PLANTAR WARTS
• Causative organism:-HPV
1,2,4,27,57
• Site:-Pressure points. on balls of
foot,esp. over the midmetatarsal area
• Lesion:-painful,gray
coloured,rounded,single or
multiple,rough to
feel,surrounded by collar of
thick skin.
• Diagnosis:-Paring of the surface
shows black dots unlike in corns
• Treatment:-Paring & 20-40%
salicylic acid,16.7% of lactic acid
or salicylic acid .
HIV/AIDS
• Mode of transmission:-Intrauterine(25%),
Intrapartum(70%), Postpartum(5%)
• Early mucocutaneous manifestation:-unresponsive or
relapsing candidiasis,molluscum
contagiousum,warts,herpes,recurrent infection with
pyogenic bacteria,dermatophytosis & scabies.
• Staging:STAGE 1:asymptomatic,persistent generalised
lymphadenopathy
STAGE 2:hepatosplenomegaly,Papular pruritic
eruptions,seborrheic dermatitis,extensive wart virus
infection,extensive molluscum contagiousum, fungal
nail infections,recurrent oral ulceration,lineal gingival
erythema,angular chelitis,hepes zoster,partotid
enlargement,rec. chronic URTIs
STAGE 3:Unexplained unresponsive
malnutrition,diarrhoea,fever. Oral candidiasis,oral
hairy leukoplakia,acute necrotizing ulcerative
gingivitis,periodontitis,pulm.TB, severe recur.
Bacterial pneumonia
STAGE 4:severe wasting,pneumocystis
pneumonia,severe bact. Infectionempyema,pyomyositis,bone or jt. Infection.
ch. Herpes simplex,extrapulm. TB,Kaposi’s
sarcoma,oesophageal candidiasis,CNS
toxoplasmosis,HIV encephalopathy
• Diagnosis:- <18 mo-PCR,viral load
ELISA
Molluscum Contagiousum in AIDS
Oral leukoplakia in AIDS
• Treatment:STAGE 4- irrespective of CD4
STAGE 3- irrespective of CD4,if >12mo with TB,LIP,OHL
or thrombocytopenia-ART may be delayed
STAGE 2- CD4 or TLC below threshold
STAGE 1- CD4 at or below threshold