Pediatric Exanthems

Sarah Stein, MDSections of Dermatology and Pediatrics

University of Chicago

Definitions

Exanthem: A skin eruption occurring as a symptom of a general disease.

Enanthem: Eruptive lesions on the mucous membranes.

Classic Childhood Exanthems

I. Measles (Rubeola)II. Scarlet FeverIII. Rubella (German measles)IV. Filatow-Dukes DiseaseV. Erythema InfectiosumVI. Roseola Infantum

1st Disease=Measles

Paramyxovirus At risk: preschool-age children who escaped

vaccination; school-age children/adolescents in whom vaccination failed

Season: late winter/spring Incubation period: 8-12days Infectious period: 1-2d before prodrome to 4d

after onset of rash

Measles: clinical features Prodrome: day 7-11 after exposure

Fever, cough, coryza, conjunctivitis Enanthem: Kopliks spots appear 2 days

before the rash, last 2 days into the rash

Measles: morbilliformexanthemPresents day 14 after exposure

Measles: complications

Otitis media Bronchopneumonia Encephalitis Myocarditis Pericarditis Subacute sclerosing panencephalitislate

sequellae due to persistent infx of the CNS

2nd Disease=Scarlet Fever

Due to erythrogenic exotoxin-producing group A beta-hemolytic streptococci

At risk:

Scarlet Fever: clinical features

Abrupt onset fever, headache, vomiting, malaise, sore throat

Enanthem Bright red oral mucosa Palatal petechiae Tongue changes

Strawberry tongues

Scarlet Fever: exanthem(12-48hrs after fever onset)

Scarlet Fever: complications

Purulent complications Otitis media Sinusitis Peritonsillar/retro-

pharyngeal abscesses Cervical adenitis

Nonsuppurativesequalae Rheumatic fever Acute

glomerulonephritis

Scarlet Fever and a negative strep culture?

Scarlet fever-like syndrome in a young adult

Arcanobacterium haemolyticum (akacorynibacterium haemolyticum) Gram positive rod Grows on 5% human blood agar More sensitive to erythromycin

3rd Disease=Rubella

Togavirus At risk: unvaccinated adolescents Season: late winter/early spring Incubation period: 14-21 days Infectious period: 5-7d before rash to 3-5d

after rash

Rubella: clinical features

Asymptomatic infection in up to 50% Prodrome

Children: absent to mild Adol and Adult: Fever, malaise, sore throat,

nausea, anorexia, painful occipital LAD Enanthem

Forschheimers spots = petechiae on the hard palate

Rubella: exanthem

Rubella: complications

Arthralgias/arthritis in older patients Peripheral neuritis, encephalitis,

thrombocytopenic purpurarare Congenital rubella syndrome

Infection during first trimester IUGR, eye findings, deafness, cardiac defects,

anemia, thrombocytopenia, skin nodules

4th Disease=Filatow-Dukes Disease

Obsolete Probably now better defined as another

clinical entity

5th Disease=ErythemaInfectiosum

Human Parvovirus B19 At risk: school-age children Season: sporadic Incubation period: 4-14 days Infectious period: up until onset of the rash

EI: clinical features

Over 50% of infections are asymptomatic Prodrome

Mild fever (15-30%), sore throat, malaise

Adultsflu-like symptoms, arthralgias/arthritis (potentially chronic), rash in up to 40%

Hematological changesproerythrocyte tropic virus Drop in RBC count

ErythemaInfectiosum:slapped cheekappearance

EI: complications

Immunocompromisedchronic infection with severe, persistent, relapsing and remitting anemia, prolonged viral shedding

Patients with decreased RBC survival time (hemoglobinopathies, hemolytic dis)aplastic crises, prolonged viral shedding

Fetal infectionhydrops fetalis (overall risk of fetal death 1-9%)

Papular purpuric glove and sock syndrome

2nd syndrome ascribed to Parvovirus B19, other viruses may be possible causes

Spring/summer; young adults Rash, LAD, fever, anorexia, arthralgias Self-limited over 7-14 days Viremia clears after rash

Papular purpuric glove and sock syndrome

6th Disease=Roseola infantum(aka Exanthem subitum)

Human Herpes Virus 6 (and 7) At risk: 6-36 mo (peak age 6-7mo) Season: sporadic Incubation period: 9 days Infectious period: virus is intermittantly

shed into saliva throughout life; asymppersistent infection

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

Roseola: exanthem

The rest of the herpes family

Herpes simplex virus 1 and 2 Varicella-zoster virus Cytomegalovirus Epstein-Barr virus Human Herpes virus 6 and 7 Human Herpes virus 8

Chicken Pox=Varicella

Varicella zoster virus, family herpesviridae At risk: young children, nonimmune inds

Second attack rate within households is 80-95% Season: sporadic Incubation period: 10-21 days Infectious period: via resp drop and vesicle

fluid, 2d before to 5d after onset of rash

Chicken Pox: clinical features

Prodrome Ranges from asymp to fever, malaise, cough,

coryza, sore throat Pruritus

Variable from mild to severe

Chicken Pox: exanthem

Chicken Pox: complications

Secondary bacterial infection5-10% Otitis media5% Higher risk for adults, neonates, immunocomp.

Pneumonitis Encephalitis Cerebellar ataxia Hepatitis

Other rare compsReye syn, Guillain-Barre, nephritis, carditis, arthritis, orchitis, uveitis

Smallpox(variola):exanthem

Herpes Zoster: clinical features

Reactivation of latent VZV in sensory ganglia

At risk: elderly, immunocomp., children who had chicken pox in utero or in 1st year

Prodrome Unusual in children In adults, dull ache for up to a week before rash

Varicella Zoster: exanthem

Cephalic herpes zoster: Ramsey-Hunt Syndrome

Varicella Zoster: complications

Post-herpetic neuralgiauncommon in kids Disseminated disimmunocompromised

Widespread cutaneous lesions Visceral disease

Ulcerations Secondary infection

Infectious Mononucleosis

Infectious Mononucleosis: and ampicillin/amoxicillin

Enterovirus rashes

Hand-foot-mouth disease Herpangina Nonspecific eruptions

Hand-foot-mouth disease

Typically due to Coxsackie A16 At risk: preschool-school aged children

Highly contagious Incubation period: 4-6 days Prodrome: 1-2 days before rash

Low-grade fever, anorexia, malaise, sore mouth

HFMD: enanthem

HFMD: exanthem

Nail matrix arrest and HFMD

Herpangina

Coxsackie A viruses At risk: young children Prodrome

Fever, sore throat

Herpangina: enanthem

Nonspecific enteroviralexanthems

Multitude of presentations Morbilliform or rubelliform Vesicular Petechial (typical of echovirus 9) Urticarial

Involvement of other systems-rare, but not to be ignored CNS, pulmonary, GI, muscular, cardiac

Enterovirus:nonspecificexanthem

Named exanthems

Gianotti-Crosti Syndrome, aka papularacrodermatitis of childhood

Unilateral Laterothoracic Exanthem, akaasymmetric periflexural exanthem of childhood (APEC)

Pityriais Rosea

Gianotti-Crosti syndrome: clinical features

Most often due to EBV, also Hep B and all other viruses

At risk: 6mo-14yrs, mean 2yrs Season: spring and early summer Constitutional symptoms: mild

Low grade fever, malaise, LAD, rare pruritus, mild hepatitis (except in Hep B-associated case)

Gianotti-Crosti Syndrome

Gianotti-Crosti Syndrome

Gianotti-Crosti Syndrome

Unilateral LaterothoracicExanthem

aka Asymmetric Periflexural Exanthem ?viral: suggested by age, clustering, resp

symptoms At risk: 1-5yos, mean 2yo Prodrome: 60-75%

Rhinitis, pharyngitis, bronchitis, conjunctivitis, gastroenteritis

Fever in 40-65%

UnilateralLaterothoracicExanthem

Pityriasis Rosea

?viral: suggested by seasonality, mild prodromal symptoms, assoc URI, clustering of cases

Season: spring, autumn, winter At risk: 10-35yos, can be seen in younger Prodrome: very mild, if any

Malaise, nausea, anorexia, headache, low fever

Pityriasis Rosea

Pityriasis Rosea

Pityriasis Rosea

Pediatric ExanthemsDefinitionsClassic Childhood Exanthems1st Disease=MeaslesMeasles: clinical featuresMeasles: complications2nd Disease=Scarlet FeverScarlet Fever: clinical featuresStrawberry tonguesScarlet Fever: exanthem(12-48hrs after fever onset)Scarlet Fever: complicationsScarlet Fever and a negative strep culture?3rd Disease=RubellaRubella: clinical featuresRubella: exanthemRubella: complications4th Disease=Filatow-Dukes Disease5th Disease=Erythema InfectiosumEI: clinical featuresEI: complicationsPapular purpuric glove and sock syndrome6th Disease=Roseola infantum(aka Exanthem subitum)Roseola: clinical featuresRoseola: exanthemThe rest of the herpes familyChicken Pox=VaricellaChicken Pox: clinical featuresChicken Pox: exanthemChicken Pox: complicationsHerpes Zoster: clinical featuresCephalic herpes zoster: Ramsey-Hunt SyndromeVaricella Zoster: complicationsInfectious MononucleosisInfectious Mononucleosis: and ampicillin/amoxicillinEnterovirus rashesHand-foot-mouth diseaseHFMD: enanthemHFMD: exanthemNail matrix arrest and HFMDHerpanginaHerpangina: enanthemNonspecific enteroviral exanthemsNamed exanthemsGianotti-Crosti syndrome: clinical featuresGianotti-Crosti SyndromeGianotti-Crosti SyndromeGianotti-Crosti SyndromeUnilateral Laterothoracic Exanthem Pityriasis RoseaPityriasis RoseaPityriasis RoseaPityriasis Rosea