Continuity Clinic

Pediatric Exanthems

Continuity Clinic

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 Clinic

Review of Terminology of Skin Lesions

Continuity Clinic

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 Clinic

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 Clinic

Description of Rashes

MACULEPUSTULE

VESICLE NODULE

Continuity Clinic

Definitions

• Exanthem – a skin eruption occurring as a symptom of a general disease

• Enanthem – eruptive lesions on the mucous membranes

Continuity Clinic

Classic Childhood Exanthems

1. Measles (Rubeola)

2. Scarlet Fever

3. Rubella (German Measles)

4. Filatow-Dukes Disease

5. Erythem Infectiousum

6. Roseola Infantum

Continuity Clinic

“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 Clinic

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 Clinic

Koplik’s Spots

Continuity Clinic

Koplik’s Spots

                                                                                          

               

 

Continuity Clinic

Exanthem of Measles

Continuity Clinic

Exanthem of Measles

                                                               

              

 

Continuity Clinic

Complications of Measles

• Otitis Media

• Bronchopneumonia

• Encephalitis

• Pericarditis

• Subacute sclerosing panencephalitis – late sequellae due to persistent infection of the CNS

Continuity Clinic

“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 Clinic

Scarlet Fever – Clinical Features

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

• Enanthem– Bright red oral mucosa– Palatal petechiae– Tongue changes

Continuity Clinic

Strawberry Tongues

Continuity Clinic

Scarlet Fever - Exanthem

                                                                                 

               

 

Continuity Clinic

Scarlet Fever - Exanthem

Continuity Clinic

Scarlet Fever - Complications

• Purulent – Otitis media– Sinusitis– Peritonsillar/retropharyngeal abscesses– Cervical adenitis

• Nonsuppurative sequalae– Rheumatic Fever– Acute glomerulonephritis

Continuity Clinic

“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 Clinic

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 Clinic

Rubella - Exanthem

Continuity Clinic

Rubella - Exanthem

Continuity Clinic

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 Clinic

“4th Disease” – Filatow Dukes Disease

• Obsolete

• Probably now better defined as another clinical entity

Continuity Clinic

“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 Clinic

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 Clinic

EI: Slapped Cheek

Continuity Clinic

EI: Exanthem

                                                                                                         

Continuity Clinic

EI: Exanthem

Continuity Clinic

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 Clinic

“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 Clinic

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 Clinic

Roseola - Exanthem

Continuity Clinic

Roseola - Exanthem