dr(mrs) m.s.panapitiya consultant paediatrician. why viral exanthum serious illness
TRANSCRIPT
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Dr(Mrs) M.S.PanapitiyaConsultant Paediatrician
Fever & rashes
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why
• Viral exanthum• Serious illness
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Main features
• Well child / ill child• Erythematous / haemorrhagic rash
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Diagnostic clues
• Association with fever• Distribution• Morphology
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Classfication of rashes
• Mobiliform rashes• Scarlantiform rashes
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Rash that looks like measles
Patients with Kawasaki disease drug reactions
The rash consists macular lesions red 2-10 mm in diameter may be confluent papular lesions solid elevated above the rest of the skin
Mobilliform rash
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• Has the pattern of scarlet fever
• has innumerable small red papules
• Patients with other conditions such as
Kawasaki disease viral infections drug reaction
Scarlatiniform rash
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• VIRAL INFECTIONS• BACTERIAL INFECTIONS• NONINFECTIVE
Aetiology
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Chicken poxHand foot mouth diseaseMeaslesRubellaFifth diseaseSixth diseaseDengue fever
Viral infections
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Erythema infectiousum
Fifth Disease
Parvovirus B19
The preceding four exanthems were1. Measles2. Scarlet fever3. Rubella 4. Atypical Scarlet fever ( Filatov-Dukes disease) 6. Roseola infantum (sixth disease)
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Benign, self-limited exanthematous illness of childhood.
The prodromal phase• low-grade fever• headache• mild upper respiratory tract infection
Fifth Disease
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Characteristic rash
occurs in three stages
1.erythematous facial flushing
"slapped-cheek" appearance.
Fifth Disease
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2. Spreads rapidly to the trunk and proximal extremities as a diffuse macular erythema
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3. Central clearing of macular lesions occurs
giving the rash a lacy, reticulated appearance.
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Palms and soles are spared,
more prominent on extensor surfaces
rash resolves spontaneously without desquamation
Fifth Disease
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Exanthem subitumSixth disease
Roseola infantum
Human herpes virus 6 (HHV-6)
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Primary HHV-6 infection occurs early in life.
Peak acquisition of primary HHV-6 infection, from 6-15 m of age
By 3-5 yr, 80-100% of children are seropositive
Roseola infantum
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The prodromal period • usually asymptomatic but may include • mild upper respiratory tract signs• mild conjunctival redness• cervical or, less frequently, occipital lymphadenopathy • mild palpebral edema.
Roseola infantum
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Clinical illness
101-106°F with an average of 103°F
irritable and anorexic
Seizures may occur in 5-10% of children Infrequently abdominal pain, vomiting, and diarrhea.
Roseola infantum
Fever persists for 3-5 days, and then typically resolves rather abruptly (crisis)
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A rash appears within 12-24 hr of fever resolution
Roseola infantum
Begins as discrete, small (2-5 mm), slightly raised pink lesions on the trunk and spreads to the neck, face, and proximal extremities
Not pruritic, and no vesicles or pustules remain discrete but occasionally may become almost confluent.
After 1-3 days, the rash fades.
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(rubeola)
Measles
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Measles has three clinical stages
Measles
Incubation stage 10-12 days
Prodromal stage 2- 4 days
Disease stage 6-10 days
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characterized by • low-grade to moderate fever• conjunctivitis • coryza • dry cough• red mottling on the hard & soft palate• Koplik spots
Measles
prodromal phase
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The pathognomonic sign of measles, appear by 2-3 days
Grayish white dots, usually as small as grains of sand
Opposite the lower molars
Koplik spots
They appear and disappear rapidly, usually within 12-18 hr.
Measles
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Measles
EXANTHEMATOUS PHASE
The temperature rises abruptly as the rash appears
neck, behind the ears, along the hairline, and on the posterior parts of the cheek
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Lesions macular, maculopapular confluent,haemorrhagic
Spreads rapidly over the entire face, neck, upper arms, and upper part of the chest within the first 24 hr
Measles
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Measles
• Mx• admit• iv fluids• vit A• antiotics• NUTRITION
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Measles
• Complictions pneumonia diarrhoea malnutrition blindness encephalitis death
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(German or three-day measles)
RUBELLAThe incubation period is 14-21 days
The prodromal phase of mild catarrhal symptoms is shorter than that of measles and may go unnoticed
Two thirds of infections are subclinical.
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most characteristic sign retroauricular, posterior cervical, and occipitalAn enanthem appears in 20% of patients just before the onset of the skin rash. discrete rose-colored spots on the soft palate (Forchheimer spots)
RUBELLALymphadenopathy.
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Exanthem •It begins on the face and spreads quickly.•Discrete maculopapules are present in large numbers•Spread rapidly over the entire body, usually within 24 hr. •May be confluent•The eruption usually clears by the third day. •Rubella without a rash has been described.
RUBELLA
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CHICKEN POX
Hand foot and mouth disease
Vesicular exanthum
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Hand foot and mouth disease
Coxsackievirus A
Coxsackie B viruses
Enterovirus 71
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It is usually a mild illness, with or without low-grade fever.
The oropharynx is inflamed and contains scattered vesicles on the tongue, buccal mucosa, posterior pharynx, palate, gingiva, and/or lips.
These may ulcerate, leaving 4-8 mm shallow lesions with surrounding erythema.
Hand foot and mouth disease
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Develop the rash on the palms of the hands, soles of the feet, maybe on buttocks. Rash is not itchy, Starts out as small, flat, red dots turn into bumps or blisters(3-7mm)
Hand, foot, and mouth disease
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They are generally more common on the extensor surfaces
Vesicles resolve in about 1 week
Hand, foot, and mouth disease
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MxSymptomaticNo specific therapy
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Vricella-Zoster Virus CHICKEN POX
Patients are contagious 24-48 hr before the rash appears and until vesicles are crusted, usually 3-7 days after onset of rash
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CHICKEN POX
Prodromal phase 24- 48 hr before the rash malaise, headache, anorexia fever - variable - resolves 2-4 days after the onset of the rash
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CHICKEN POX
•The rash often appears first on the scalp, face, or trunk. •It can then spread over the entire body.
Ulcerative lesions involving the oropharynx are common
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• Blisters on a pink base • Dry brown crusts
• New waves of blisters often spring up as the illness progresses
CHICKEN POXVricella-Zoster Virus The initial exanthem
The initial exanthem • Intensely pruritic • Erythematous macules• Papular stage
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Varicella is a more serious disease with higher rates of complications and deaths among infants, adults, and immunocompromised patients.
CHICKEN POXVricella-Zoster Virus
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The initial infection is intrauterine, although the newborn often develops clinical chickenpox postpartum.
Newborn with varicella
Newborns have particularly high mortality around the time of delivery.
Maternal varicella one week before or 2 days after birth frequently results in the newborn developing severe varicella
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Newborn with varicella
Rx : ZSIG IV Acyclovir
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CONGENITAL VARICELLA SYNDROME
Up to 2% of fetuses whose mothers had varicella in the first 20 weeks of pregnancy may demonstrate VZV embryopathy
Fetuses infected at 6-12 wk of gestation appear to have maximal interruption with limb development at 12-20 wk may have eye and brain involvement
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Stigmata of Varicella-Zoster Virus Fetopathy
Cicatricial skin lesions Hypopigmentation
Microphthalmia Cataracts Chorioretinitis Optic atrophy
Microcephaly Hydrocephaly Calcifications Aplasia of brain
Hypoplasia of an extremity Motor and sensory deficits Absent deep tendon reflexes
SkinEyeBrainLimbs
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Varicella vaccine
• Live virus vaccine• Recommended for children at 12-18 mo• Can be given at any age• Children 12 mo to 12 yr receive a single
vaccine dose• Adolescents and adults require 2 vaccine
doses, a minimum of 4 wks apart
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Usually very mild
Breakthrough varicella
2-6 weeks after vaccination
Could be due to either the wild or vaccine strains
Potentially infectious
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Scarlet fever
Upper respiratory tract infection associated with a characteristic rash
Infection with pyrogenic exotoxin producing group A streptococcus
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The rash appears within 24-48 hr after onset of upper respiratory symptoms
begins around the neck and spreads over the trunk and extremities
Scarlet fever
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Scarlet feverDiffuse, finely papular, erythematous eruption producing a bright red discoloration
Blanches on pressure
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More intense along the creases of the elbows, axillae, and groin
Scarlet fever
P
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Cheeks may be erythematous with pallor around the mouth.
Scarlet fever
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Pharynx is red
The tongue is usually coated and the papillae are swollen
After desquamation, the reddened papillae are prominent, giving the tongue a strawberry appearance.
Scarlet fever
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After 3-4 days, the rash begins to fade and is followed by desquamation
Sheetlike desquamation may occur around the free margins of the fingernails, the palms, and the soles.
Scarlet fever
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Treatment•Group A streptococcus is sensitive to penicillin, and resistant strains have never been encountered. •Penicillin is, therefore, the drug of choice (except in patients who are allergic to penicillin) •Treatment with oral penicillin V for 10 days is recommended •It must be taken for a full 10 days even though there is symptomatic improvement in 3-4 days
Scarlet fever
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Toxic shock syndrome is caused by a toxin produced by certain types of Staphylococcus bacteria.
A similar syndrome, called toxic shock-like syndrome (TSLS), can be caused by Streptococcal bacteria.
Toxic shock syndrome
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Toxic shock syndromeThe onset is abrupt high fever vomiting diarrhea sore throat headache myalgia
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Very ill
Alteration in the level of consciousness
Oliguria, hypotensionprogress to shock
Disseminated intravascular coagulation
Toxic shock syndrome
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Toxic shock syndrome
• Exanthum A diffuse erythematous macular rash
(scarlatiniform) appears within 24 hr
Hyperemia of pharyngeal& conjunctival, mucous membranes
Strawberry tongue is common
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Fever lasting for at least 5 days
Presence of at least four of the following five signs:
Kawasakie disease
Diagnostic criterias
Fever lasting for at least 5 days
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1. Bilateral bulbar conjunctival injection, generally nonpurulent
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2. Changes in the mucosa of the oropharynx, injected pharynx red, dry & fissured lips strawberry tongue
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3.Changes of the peripheral
extremities
Edema and/or erythema of the hands or feet in the acute phase
Periungual desquamation in the subacute phase
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4.Rash, primarily truncal polymorphous but nonvesicular
Rash of various forms (maculopapular, erythema multiforme, or scarlatiniform) with accentuation in the groin area
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5.Cervical adenopathy, ≥1.5 cm usually unilateral nonpurulent
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Mycoplasma pneumoniae
• Skin lesions include a variety of exanthems, most notably
Maculopapular rashes Erythema multiforme Stevens-Johnson syndrome
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Petecial rash - Usually found on the limbs this rash is as a result of bleeding under the skin surface.
Bright red rash - skin becomes florid and bright red in appearance. there will be some 'normal' areas of skin which are unaffected.
A transient, macular, generalized rash that blanches under pressure may be seen during the first 24-48 hr of fever.
A generalized, morbilliform, maculopapular rash appears that spares the palms and soles. Rarely there is edema of the palms and soles.
Dengue fever rash
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Thank you
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TRANSIENT APLASTIC CRISIS.
•The incubation period for is shorter than for erythema infectiosum because it occurs coincident with the viremia.
•B19-induced aplastic crises occur in patients with all types of chronic hemolysis
•These patients are ill with fever, malaise, and lethargy and have signs and symptoms of profound anemia
•Rash is rarely present.
?TRANSIENT APLASTIC CRISIS
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Primary maternal infection is associated with nonimmune fetal hydrops and intrauterine fetal demise
The mechanism of fetal disease appears to be a viral-induced red cell aplasia at a time when the fetal erythroid fraction is rapidly expanding.
C0NGENITAL INFECTION(PARVOVIRUS B19)
The second trimester seems to be the most sensitive period, but fetal losses are reported at every stage of gestation
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• probably the most common cause of stomatitis in children 1-3 yr of age, • The symptoms may appear abruptly, with pain in the mouth, salivation,
fetor oris, refusal to eat, and fever, often as high as 40-40.6°C• Fever and irritability may precede the oral lesions by 1-2 days. • The initial lesion is a vesicle which is seldom seen because of its early
rupture. • The residual lesion is 2-10 mm in diameter and is covered with a yellow-
gray membrane. • the tongue and cheeks are most commonly involved, no part of the oral
lining is • Submaxillary lymphadenitis is common.• The acute phase lasts 4-9 days and is self-limited
ORAL HSV PRIMARY INFECTION
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reatmentAny foreign materials, such as tampons, vaginal sponges, or nasal packing, will be removed. Sites of infection (such as a surgical wound) will be drained.The goal of treatment is to maintain important body functions. This may include:Antibiotics for any infection (may be given through an IV)Dialysis (if severe kidney problems are present)Fluids through a vein (IV)Methods to control blood pressureIntravenous gamma globulin may help in severe cases
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Dukes' disease or fourth diseaseAn exanthem-producing infectious disease of childhood of unknown aetiology. Synonym: Filatov's disease, fourth disease,
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Signs and testsNo single test can diagnose toxic shock syndrome.The diagnosis is based on several criteria: fever, low blood pressure, a rash that peels after 1-2 weeks, and problems with the function of at least three organs.In some cases, blood cultures may be positive for growth of S. aureus.Treatment