Childhood Exanthemata

Dr. Philip G. MurphyConsultant Microbiologist,

AMNCH,Tallaght.

Aetiology• Exanthem = exterior rash

Measles

Rubella

Varicella (chickenpox)

Scarlet fever

Parvovirus

HH6

(Kawasaki Disease)Other childhood fevers:Mumps, Whooping cough, Diphtheria

NSROC

MeaslesMeaslesRubeola (RNA morbillivirus)Rubeola (RNA morbillivirus)

• Incubation: 7-14 d

• Prodrome: 4 -5 d before rash

fever, malaise, coryza, sneezycough,

Koplik spots1-3 d before rash

• Rash: day 4-7 of illness

starts behind ears, forehead, around mouth

dusky red, florid maculopapular rash spreads over trunk and limbs. Lasts 5 d.

• Infectivity: prodrome to 4 d after the rash

• Transmission: respiratory droplet or direct contact

• Complications: ears & OM,

lungs & pneumonia

conjunctivitis

CNS encephalitis at d 10, SSPE after several years

MeaslesMeasles• Highly contagious acute viral illness caused by a

paramyxovirus, genus Morbillivirus

• One of the leading causes of child mortality in developing countries - 10% of all deaths of children < 5 years.

• Measles eradication possible – no longer endemic in U.S.

• Europe: Outbreaks reported in Germany 1996, 1999 and 2000, Netherlands 1999 (2600 cases and 3 deaths).

Measles vaccinationMeasles vaccination• Measles vaccination in Ireland since 1985

• Vaccination rates of 95% necessary to eliminate spread

• Vaccination coverage of 70 – 80% at 24 months of age in the Eastern Regional Health Authority

• Outbreak of measles occurred between December 1999 and July 2000. Majority of cases in TCH catchment area.

Notifications of measles, January 1991-September 2000, Dublin, Wicklow and Kildare

0

500

1000

1500

2000

2500

3000

91 92 93 94 95 96 97 98 99 00

year

No

case

s

Measles by week of notification Area Health Boards

1 January-28 October 2000

0

10

20

30

40

50

60

70

80

90

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43

Week of notification

No

case

s no

tifie

d

Northern AHB

South Western AHB

East Coast AHB

Eastern Regional Health Authority

Number (%)

Total number attending TCH 355Number admitted to TCH 111 Underlying chronic or acute illnesses 29 (26)Number admitted to ICU 13 (11)Mortality 3

Range Median

Inpatient stay 1 - 43 5

ICU stay 1 - 28 6

12.00%

27.00%

61.00%

Yes No Record No

MMR Status of Measles Cases in Northern MMR Status of Measles Cases in Northern Area Health Board (n=567):Area Health Board (n=567):

0

10

20

30

40

50

60

70

80

90

Deh

ydra

tion

Pn

eum

onit

isan

dP

neu

mon

ia

Tra

chei

tis

Indication for admissionIndication for admission

Symptoms and Signs

0

20

40

60

80

100

120

Number

Of

Patients

Exanthem

Pyrexia

Cough

Conjunctivitis

Vomiting

Diarrhoea

Otitis Media

Febrile Seizure

Apnoea

95% 95% 84%

54% 40% 39% 33%

8%

Control

• Public Health– Outbreak Control Team set up by NDSC– Measles/Mumps/Rubella (MMR) vaccination

• Brought forward to 12 months of age• Given at 6 months in our area• Repeated at 15 months• Second MMR brought forward to 4 years of age• Opportunistic vaccination in schools and creche

– Recalled non-attenders– Press releases

FutureFuture

• Oireachtais Committee Report– Co-ordinator to oversee vaccine program– Dedicated administrative and nursing staff– Modernisation of Civil Registration Service

• Personal public service number– Improved IT at health board level– Vaccine information statements to parents– Continuous immunisation campaigns in media until rate >

95%• Guidelines for future outbreaks

Varicella (chickenpox, shingles)Varicella (chickenpox, shingles)• Incubation: 12-21 d

• Prodrome: 1 d before rash

fever, malaise

• Rash: oval macule progressing to macule and then pustules which heal and crust. Appears as crops centrally

then peripherally

• Other: may be marked fever for 2-3 d., then settles

• Infectivity: 5d before to 5 d after the rash

• Transmission: respiratory droplet or direct contact

• Complications:Rare:encephalitis after 10d

pneumonia especially immune suppressed

20 bacterial skin infection

Shingles

• Diagnosis: EM, CFT

• Treatment: aciclovir, topical disinfectants, ZIG if immune suppressed

RubellaRubella• Incubation: 14-23 d

• Prodrome: none or mild fever1d before rash

• Rash: none or for 1-3 d a pink macular rash on face and trunk

otherwise well

sub-occipital lymphadenopathy

arthralgia /polyarthritis in older child or adult

rarely thrombocytopaenia

• Infectivity: 7d before to 5 d after the rash

• Transmission: respiratory droplet or direct contact

• Complications: in utero - congenital rubella syndrome,

deafness,cataracts, cardiac abnormalities hepatomegaly, splenomegaly, purpura. 30% mortality.

25% if exposure in first 4months, 60-80% in 1st month

rarely encephalitis at 10d

Kawasaki DiseaseKawasaki Disease

• Unknown aetiology ?? Infective

• fever, rash,

• conjunctivitis, hand/feet dorsae induration

• stomatitis, strawberry tongue, lymphadenopathy

• coronary artery narrowing - aneurysm, thrombosis and MI

• desquamation in recovery

• Rx: Immuneglobulin

Erythema infectiosum Erythema infectiosum (Fifth Disease, Slapped ckeek syndrome)(Fifth Disease, Slapped ckeek syndrome)

• Parvovirus B19, ssDNA, 22 nm diameter

• Rash on cheeks, flitting and later lace-like on trunk

• More severe in adults with arthritis and lymphadenopathy

• benign course and rare complications

• transient marrow depression and rarely aplastic crisis

Exanthem subitumRoseola infantum;Sixth Disease

• Human Herpes virus 6

• commonly seroconversion by 2 years

• 3-5 d fever, urti

• 20% exanthem: classic maculopapular rash

• common in CNS – but ? Role in multiple sclerosis

Scarlet feverScarlet fever• Aetiology; Streptococcus pyogenes (Group A)• Pathogenesis: erythrogenic toxin• Incubation: 1-3 d • Prodrome: 1-2 d fever,sorethroat,headache,flushed

cheeks• Rash: punctate erythematous central and blanches• Signs: circumoral palor, strawberry tongue, desquamation post rash• Infectivity: up to 3 weeks or 24h after pen• Transmission: respiratory• Complications: septicaemia, endocarditis, OM, Quinsy

rheumatic fever, acute nephritis