pediatricexanthems

8/6/2019 PediatricExanthems

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Pediatric ExanthemsPediatric Exanthems

Deborah J BostockDeborah J Bostock

Col, USAF, MCCol, USAF, MCFamily Medicine and GeriatricsFamily Medicine and Geriatrics


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Classic ReferenceClassic Reference

Exanthems and Drug EruptionsExanthems and Drug Eruptions

Habif: Clinical Dermatology, 4thHabif: Clinical Dermatology, 4thed.ed., Copyright 2004 Mosby, Inc., Copyright 2004 Mosby, Inc.


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Review article:Review article:

Pediatric exanthemsPediatric exanthems Clinics in Family PracticeClinics in Family PracticeVolume 5 Number 3 SeptemberVolume 5 Number 3 September

20032003Copyright 2003 W. B. SaundersCopyright 2003 W. B. SaundersCompanyCompany

Jeffrey D. Wolfrey, MDJeffrey D. Wolfrey, MD **William H. Billica, MDWilliam H. Billica, MD

Scott H. Gulbranson, MDScott H. Gulbranson, MDAlaina B. Jose, MDAlaina B. Jose, MDMark Luba, MDMark Luba, MD

Andrew Mohler, MDAndrew Mohler, MDCheryl Pagel, MDCheryl Pagel, MDJarrett K. Sell, MDJarrett K. Sell, MD


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In antiquity, these illnesses were allIn antiquity, these illnesses were alllumped together.lumped together.

Eventually, a distinction was madeEventually, a distinction was madebetween measles and pox (withbetween measles and pox (withgrowing clarity over about agrowing clarity over about amillennium).millennium).


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Six separate childhood exanthemsSix separate childhood exanthemswere defined from what was oncewere defined from what was once

called the measles.called the measles. In the early part of the 20th century,In the early part of the 20th century,

these were often referred to bythese were often referred to bynumbernumber


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PoxesPoxes

Chickenpox and SmallpoxChickenpox and Smallpox

the other two classic childhoodthe other two classic childhoodexanthemsexanthems

recognized as separate from eachrecognized as separate from eachother in the 18th century.other in the 18th century.

These both had blisters, or pox,These both had blisters, or pox,that set them apart from the redthat set them apart from the redrashes of the other grouprashes of the other group


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Classic Childhood ExanthemsClassic Childhood Exanthems

1.1. MeaslesMeasles

2.2. Scarlet feverScarlet fever

3.3. RubellaRubella (German measles)(German measles)

4.4. Atypical scarlet feverAtypical scarlet fever

5.5. Erythema InfectiosumErythema Infectiosum

6.6. RoseolaRoseola


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Today, dozens of exanthemsToday, dozens of exanthems

are recognized:are recognized: AdenovirusAdenovirus

AnthraxAnthrax

MononucleosisMononucleosis

Colorado tickColorado tickfeverfever

MumpsMumps CatCat--scratch feverscratch fever

RatRat--bite feverbite fever

Rocky MountainRocky Mountainspotted feverspotted fever

Relapsing feverRelapsing fever MeningococcemiaMeningococcemia

TyphusTyphus

HandHand--footfoot--mouthmouthdiseasedisease


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#1#1-- MeaslesMeasles

VirusVirus: Rubeola: Rubeola

DemographicsDemographics Winter or springWinter or springInfancy to young adulthood 8Infancy to young adulthood 8-- to 12to 12--day incubation Epidemics until 96%day incubation Epidemics until 96%immunizedimmunized

ProdromeProdrome 224 days. High fever,4 days. High fever,cough, coryza, conjunctivitis,cough, coryza, conjunctivitis,photophobia, Koplik spots, lethargy,photophobia, Koplik spots, lethargy,

sneezing.sneezing.


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#1 Measles#1 Measles

Rash and DiseaseRash and Disease EnanthemEnanthem: Koplik spots: Koplik spots == graygray

pinheads, ring of erythema, buccalpinheads, ring of erythema, buccal

mucosa. 0.5mucosa. 0.52d.2d. ExanthemExanthem: erythematous blanching: erythematous blanching

macules.macules. Starts forehead, spreads downwardStarts forehead, spreads downward

Confluent by 72 hrConfluent by 72 hr

Spares palms, and soles, 4Spares palms, and soles, 46 days.6 days.

Toxic appearance.Toxic appearance.


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DiagnosisDiagnosis Leukopenia, IgG and IgMLeukopenia, IgG and IgMserologies, acute and convalescentserologies, acute and convalescent

titerstiters TreatmentTreatment Symptomatic.Symptomatic.Antipyretics.Antipyretics. In severe disease, vitamin A.In severe disease, vitamin A.


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ComplicationsComplications Otitis media, diarrhea,Otitis media, diarrhea,pneumonia (common in atypicalpneumonia (common in atypical

rubeola).rubeola). Rarely, laryngoRarely, laryngo--tracheobronchitis,tracheobronchitis,

myocarditis, encephalitis. Subacutemyocarditis, encephalitis. Subacutesclerosing panencephalitissclerosing panencephalitis


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PreventionPrevention Vaccinate all at 12Vaccinate all at 1218 mo.18 mo.

Two doses for 13 years and older.Two doses for 13 years and older.

PostPost--exposure vaccine if immunoexposure vaccine if immuno--compromisedcompromised

VZIG if pregnant, premature, orVZIG if pregnant, premature, orimmunocompromisedimmunocompromised


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#2#2-- Scarlet FeverScarlet Fever

Rash and DiseaseRash and Disease Strawberry tongueStrawberry tongue

Exudative pharyngitisExudative pharyngitis

Generalized; spares palms and solesGeneralized; spares palms and soles

Pinpoint papulesPinpoint papules

Desquamation of the tips of the fingers andDesquamation of the tips of the fingers and

toestoes


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#2 Scarlet Fever#2 Scarlet Fever

DiagnosisDiagnosis

Group A streptococcal positive throatGroup A streptococcal positive throat

cultureculture

Elevated WBC count and ESRElevated WBC count and ESR

TreatmentTreatment : penicillin,: penicillin,

cephalosporins, erythromycin,cephalosporins, erythromycin,ofloxacin, rifampin, or the newerofloxacin, rifampin, or the newermacrolidesmacrolides


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#3#3-- RubellaRubella

VirusVirus: Rubivirus (Rubella): Rubivirus (Rubella)

DemographicsDemographics

5514 yr before vaccines14 yr before vaccines

Now teens and young adults 2Now teens and young adults 2-- to 3to 3--wkwk

ProdromeProdrome

Mild catarrhal symptoms, oftenMild catarrhal symptoms, oftenoverlooked.overlooked.

Marked tender lymphadenopathy seen 24Marked tender lymphadenopathy seen 24

hr before rashhr before rash


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#3 Rubella#3 Rubella

Rash and DiseaseRash and Disease ExanthemExanthem::

Starts face, spreads by 24 hr to trunk,Starts face, spreads by 24 hr to trunk,

extremities.extremities.

Day 1: 1Day 1: 1-- to 4to 4--mm macules, usuallymm macules, usuallydistinct, sometimes reticular.distinct, sometimes reticular.

Day 2: pinpoint papules.Day 2: pinpoint papules. Day 3: clears. Sometimes mildDay 3: clears. Sometimes mild

desquamation.desquamation.

LowLow--grade fever, pruritus possible.grade fever, pruritus possible.


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DiagnosisDiagnosis

Acute and convalescent titersAcute and convalescent titers

rubella IgM antibody (esp. for exposedrubella IgM antibody (esp. for exposedpregnant women)pregnant women)

TreatmentTreatment

Symptomatic.Symptomatic. NSAIDs for arthritis.NSAIDs for arthritis.


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ComplicationsComplications

SelfSelf--limiting polyarthritis in girls, younglimiting polyarthritis in girls, young

women. Hands and wrists, large jointwomen. Hands and wrists, large jointeffusions.effusions.

Fetuses of nonimmune women infectedFetuses of nonimmune women infectedmay have deafness, eye, cardiac andmay have deafness, eye, cardiac andendocrine anomalies, and retardation.endocrine anomalies, and retardation.


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PreventionPrevention Vaccine at 12Vaccine at 1215 mo15 mo

Second dose at 11Second dose at 1112 yr.12 yr.

Immune globulin not indicated.Immune globulin not indicated.


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#4#4-- Atypical Scarlet FeverAtypical Scarlet Fever


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#5#5-- Erythema InfectiosumErythema Infectiosum

VirusVirus: Parvovirus B19: Parvovirus B19

Demographics:Demographics:

SpringSpring

5517 yr17 yr

44-- to 21to 21--d incubationd incubation

ProdromeProdrome LowLow--grade fever, headache,grade fever, headache,

malaise.malaise.


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Rash and DiseaseRash and Disease Slapped cheeks facial erythema withSlapped cheeks facial erythema with

abrupt onsetabrupt onset Circumoral and perioral pallor, sparingCircumoral and perioral pallor, sparing

of nasal bridge.of nasal bridge. Body develops pale maculopapularBody develops pale maculopapular

exanthem; may involve palms andexanthem; may involve palms andsoles. Lasts 3soles. Lasts 35 days5 days

Atypically, PapularAtypically, Papular--PurpuricPurpuric Gloves andGloves and Socks syndrome (onlySocks syndrome (only

hands and feet affected)hands and feet affected)


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DiagnosisDiagnosis

IgM and IgG serologies, acute andIgM and IgG serologies, acute and

convalescent antibody titers, DNAconvalescent antibody titers, DNAhybridizationhybridization

TreatmentTreatment

Symptomatic.Symptomatic. IVGG and transfusions if hematologicIVGG and transfusions if hematologic

complicationscomplications


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ComplicationsComplications In anyone:In anyone:

HenochHenoch--Schonlein purpura,Schonlein purpura,

Polyarteritis nodosaPolyarteritis nodosa Infectious mononucleosis.Infectious mononucleosis.

In HIV+ or those with hemolyticIn HIV+ or those with hemolyticanemia:anemia:

aplastic anemia.aplastic anemia. In pregnancy: fetal hydrops orIn pregnancy: fetal hydrops or

stillbirth.stillbirth.


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No vaccine.No vaccine.

No isolation once symptomaticNo isolation once symptomatic (not(notcontagious);contagious);

Pregnant women should avoidPregnant women should avoidoutbreak sites for 3 wk and getoutbreak sites for 3 wk and get

serologic testing.serologic testing.


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#6#6-- RoseolaRoseola

VirusVirus: HHV: HHV--6 /HHV6 /HHV--77

DemographicsDemographics 003 yr3 yr

Prodrome:Prodrome:

335 d intermittent fever to 40.55 d intermittent fever to 40.5C.C.

Child appears well.Child appears well.


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Rash and DiseaseRash and Disease ExanthemExanthem::

002 d after defervesces2 d after defervesces

11-- to 5to 5--mm rose macules with pale areolamm rose macules with pale areoladensest on neck and trunk.densest on neck and trunk.

Can get confluent.Can get confluent.

Lasts 1Lasts 13 d.3 d.

EnanthemEnanthem: pinpoint papules or streaks on: pinpoint papules or streaks onuvula, soft palate. LAD, periorbital edema,uvula, soft palate. LAD, periorbital edema,cough, headache, coryza, abdominal pain.cough, headache, coryza, abdominal pain.


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DiagnosisDiagnosis

Clinical.Clinical.

Specific IgM and IgG for acute andSpecific IgM and IgG for acute andconvalescent titers not widelyconvalescent titers not widelyavailable.available.

TreatmentTreatment Symptomatic. Antipyretics for fever.Symptomatic. Antipyretics for fever.


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ComplicationsComplications Febrile seizures.Febrile seizures.

More rarely:More rarely:

mononucleosismononucleosis neonatal hepatitisneonatal hepatitis

fatal hemophagocytic syndromefatal hemophagocytic syndrome

encephalitisencephalitis thrombotic thrombocytopenic purpurathrombotic thrombocytopenic purpura

Prevention: nonePrevention: none


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Hand, Foot, and Mouth diseaseHand, Foot, and Mouth disease

aka Papularaka Papular--purpuric gloves and socks syndromepurpuric gloves and socks syndrome

VirusVirus: Enteroviruses: Enteroviruses


Summer (less pronouncedin tropics)Summer (less pronouncedin tropics)

6 mo to 13 yr6 mo to 13 yr

ProdromeProdrome Brief. Sore throat,Brief. Sore throat,

anorexia, malaise, lowanorexia, malaise, low--grade fever.grade fever.


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Hand, Foot, and MouthHand, Foot, and Mouth

disease Rash and Diseasedisease Rash and Disease EnanthemEnanthem::

Oral mucosal vesicles that erode to formOral mucosal vesicles that erode to form

ulcers 2 mm to 2 cm in diameter.ulcers 2 mm to 2 cm in diameter.

Painful!Painful!

ExanthemExanthem::

33-- to 7to 7-- mm vesicles on dorsal hands,mm vesicles on dorsal hands,feet, and sometimes palms, sole.feet, and sometimes palms, sole.

Tender, pruritic, or asymptomaticTender, pruritic, or asymptomatic


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B19


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Hand, Foot, and MouthHand, Foot, and Mouth

diseasedisease DiagnosisDiagnosis

ClinicalClinical

Specific serotype testing should clinicianSpecific serotype testing should cliniciansuspect a particular enterovirussuspect a particular enterovirus

TreatmentTreatment

Symptomatic. Analgesia to helpSymptomatic. Analgesia to help childchildwith oral intake, steroids for itchwith oral intake, steroids for itch


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DDx of an ErythematousDDx of an Erythematous

Maculopapular RashMaculopapular Rash RubellaRubella

RubeolaRubeola

Scarlet feverScarlet fever

Kawasaki diseaseKawasaki disease

Secondary syphilisSecondary syphilis

Drug eruptionDrug eruption

Coxsackie virusCoxsackie virus

ECHO virusECHO virus

AdenovirusAdenovirus

InfectiousInfectiousmononucleosismononucleosis

ParvovirusParvovirus

MeningococcemiaMeningococcemia

ToxoplasmosisToxoplasmosis

Serum sicknessSerum sickness

Rickettsial disease (eg,Rickettsial disease (eg,

Rocky MountainRocky MountainSpotted fever)Spotted fever)

RoseolaRoseola


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Virus/SyndromeVirus/Syndrome::


ProdromeProdrome

Rash and DiseaseRash and Disease

DiagnosisDiagnosis

TreatmentTreatment

ComplicationsComplications


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