Rash illness

PROF.DR.YILDIZ CAMCIOĞLU

Importance

A very important sign of the disease Avoid persons to be infected, İmportant for public health

exa: meningoccoccemia Differential diagnosis is done by history of rash,

clinical findings, laboratory results,

Definition

EXANTHEM is rash on skin Lesions at mucosa are called ENAMTHEM

MACULE: Red lesion due to capillary dilatation, if you press

on by a glass it fades

Papule

PAPULE:Red and palpable nodular lesion due to capillary dilatation, elevated from skin generally it fades if you press on it by a glass

Vesicle is a small blister containing clear fluid, may be scattered irregularly over skin or grouped in cluster

Pustule is a small elevation of skin containing pus

ERYTHEMA

Localized or diffuse

erythema of skin

Scarlatina or erithema marginatum

PURPURIC RASHES Petechia: a small haemorrhage beneath the epidermis Ecchymoses is a larger area of

haemorrhage

Erythema Nodosum Painful, tender, firm, raised round, or oval

subcutaneous nodules At first brigth red, then change to o bluise

purple Occur over the thights and tibia

Approach to a child with rash

1- History of lesion *Date of the appearance. * Place of first appeared *Distrubution, appearance and fading * sense of pain, burning, parahestesia,

pururitus2- Experienced rash illness3- Vaccination4- Family history: eczema, astma, allergic rhinitis5- Breast feeding

6- Rash illness at family, siblings, neigbourhood and school

7- Rash stimulated by:Uv, heat, food, drug, infection.

8- Other findings *Fever *Tonsillitis *Arthralgy *Growth retardation *Adenomegaly *Hepatosplenomegaly *Ichterus

EXANTEM SUBITUM, 6th Disease(ROSEOLA INFANTUM) ET: Human herpesvirus-6)EPİ: Common in fallIncubation period: 7-17 days most frequent between 6-18 months CLİNİCAL FİNDİNGS:undifferentiated febrile illness

without rash or localizing signs, Fever characteristically is high (temperature greater

than 39.5°C [103.0°F]) and persists for 3 to 7 days. Maculopapular rash lasting hours to days is noted

once fever resolves Febrile seizures occur during the febrile period in

approximately 10% to 15% of primary infections A bulging anterior fontanelle occurs occasionally

EXANTEM SUBITUM (ROSEOLA INFANTUM) , 6th disease

Differential diagnosis Clinical findings Laboratory: Leucocytosis and granulocytosis

on first 24-36 hours than leucopenia develops on the second day of illness

No specific test for diagnosis

No drug to treart

Fifth Disease;Erythema infectiosum

A viral infection caused by parvovirus B19 Parvovirus B19 commonly infects humans

About 50% of all adults have been infected during childhood or adolescence

Infected people have the virus in their saliva and mucus You can get it when you come into contact with those

fluids Most people become immune to the virus after having

it once

5th Disease(ERYTHEMA INFECTIOSUM)

EPİDEMİOLOGY Epidemic at spring Common in school children

Incubation period : 4-14 days

Leads haemolytic crisis in patients with Chronic haemolitic anemia, sickle cell, spherocytosis Decreases reticulocyt count in healthy children

Symptoms

Low fever, cold symptoms The ill child typically has a "slapped-cheek"

rash on the face A lacy red rash on the trunk and limbs Occasionally, the rash may itch. The child is usually not very ill, and the rash

resolves in 7 to 10 days. Once a child recovers from parvovirus

infection, he or she develops lasting immunity,

Adults who get it might also have joint pain and swelling.

Joint pain and swelling in adults usually resolve without long-term disability

Fifth disease can be serious in; Pregnant women

In less than 5% of all pregnant women parvovirus B19 infection may cause a baby born with severe anemia or miscarriage. There is no evidence that parvovirus B19 infection causes birth defects or mental retardation

Anemic children Have cancer or a weak immune system

A blood test for parvovirus B19 may show:

1) that you are immune to parvovirus B19 and have no sign of recent infection

IgG(+)

2) That you are not immune and have not yet been infected

IgG and IgM(-)

3) that you have had a recent infection

IgM(+)

RUBELLA Etiology: Togaviridae family Rubivirus Genus RNA virus EPİDEMİOLOGY: Host is only humans, droplet infection

Incubation period: 14-21 days. Prodromal stage: Mild cataral symptoms. Retroauricular, posterior cervical, occipital LAP

The cause of rubella A virus that's passed from person to person. It can spread when an infected person coughs or sneezes, or it

can spread by direct contact Transmitted from a pregnant woman to her unborn child. A person with rubella is contagious from one week before the

onset of the rash until about one to two weeks after the rash disappears

The disease is still common in many parts of the world, although more than half of all countries now use a rubella vaccine

The prevalence of rubella in some other countries is something to consider before going abroad, especially if you're pregnant

Signs and symptoms of rubella So mild that they're difficult to notice, especially in children. If signs and symptoms do occur, they typically last about two to

three days and may include: Mild fever of 102 F or lower Headache Stuffy or runny nose Inflamed, red eyes Enlarged, tender lymph nodes at the base of the skull, the back

of the neck and behind the ears A fine, pink rash that begins on the face and quickly spreads to

the trunk and then the arms and legs, before disappearing in the same sequence

Aching joints, especially in young women

Tests and diagnosis

The rubella rash can look like many other viral rashes.

Discrete

Last 3 days

Without any mark

A virus culture IgG or IgM antibodies in blood

Rubella

Diagnosis: 4 time increase IgG antibody or

IgM(+)

Vaccine:

MMR 15-18 months and , 6-12 years of age

Differential Diagnosis : Scarlet fever, Measles, 6th disease, enteroviral inf, infectious mononucleus, drug eruption .

Treatment

Usually no need Isolation from others — especially pregnant

women — during the infectious period. If a pregnant woman contract to a child with

rubella ; hyperimmune globulin can be recommended

This can reduce symptoms but doesn't eliminate the possibility of baby developing congenital rubella syndrome

Complications

In rare cases, rubella can cause: Artritis ( on 2nd -3rd days) Encephalitis: 1/6000 Purpura: Thrombocytopenic or

nonthrombocytopenic Congenital rubella

1941 reported by Gregg 1964 Epidemic in USA Up to 85 percent of infants born to mothers who had

rubella during the first 11 weeks of pregnancy develop congenital rubella syndrome

This can cause one or more problems, including growth retardation, cataracts, deafness, congenital heart defects and defects in other organs

The highest risk to the fetus is during the first trimester, but exposure later in pregnancy also is dangerous

.

Congenital Rubella

MEASLES

ETIOLOGY : RNA paramixovirus.EPİDEMİOLOGY : 5-10 years of age most frequentPATHOLOGY : Prodromal stage ; Hyperplasia of lymphoid tissue

Coplic spots; intercellular and intracellular edema, parakeratosis, dsykeratosis

Lungs: Peribronchial inflammation, interstisial mononuclear cell infiltration

Cerebrum and M.spinalis: Edema, congestion and peteshial haemorage

Incubation period: 8-12 days.

Transmission of Measles Spread by contact with an infected person, through

coughing and sneezing (highly contagious) The disease can be transmitted from 4 days prior to the

onset of the rash to 4 days after the onset. If one person has it, 90% of their susceptible close contacts will also become infected with the measles virus.

The virus resides in the mucus in the nose and throat of the infected person. When that person sneezes or coughs, droplets spray into the air.

The virus remains active and contagious on infected surfaces for up to 2 hours.

Pathological stages of Measles 0 day : The virus attachs epithelium of nose and throat

of the infected person. Virus begin to replicate within epithelium 1-2 day: Virus spreads to local lymph nodes 2-3: Primary viremia. 3-5: Virus begin to replicate at bronchial epithelium,

RES and distance areas 5-7: Secondary viremia. 7-11: Clinical findings on skin and infected areas 11-14: Virus can be isolated from blood, respiratory

system, skin and other tissues 14-17: Viremia disappaers, amount of virus at tissues

decreases

CLİNİCAL findings Prodromal period Symptoms

high fever, cough, runny nose, and red, watery eyes (lasts about a week), Coplic spots, stimson lines

Rash stage: Erythematous maculopapular are confluent Rash begins from hair-neck line, behind the ears 3rd day lesions distrubute over the foot 3-4 days later brownish spots observed instead of rash Fine desquamation also noticed Malaise can accompain to fever (+), Generalised lymphoadenopathy may be observed. Diarrhea may be seen in infancy:24-36 hours later fever decreases and symptoms disappear

Complications Approximately 20% of reported measles cases experience one

or more complications common under 5 years of age ear infections in nearly 1/10 children 1/20 children gets pneumonia, 1/1,000 will develop encephalitis. 1-2/1,000 children will die pregnant woman have a miscarriage, give birth prematurely,

or have a low-birth-weight baby. In developing countries, where malnutrition and vitamin A

deficiency are prevalent, measles has been known to kill as many as 1/4 four people.

It is the leading cause of blindness among African children. Measles kills almost 1 million children in the world each year.

MEASLESCOMPLİCATIONS: Otitis, interstisial pneumonia, Secondary bacterial infections, Anergy to TB 1-2/1000 encephalomyelitis Myocarditis and mesenteric adenitis.TREATMENT: Symptomatic.A vitamine; 6 m-1 years A vit. 100 000 iU 1-2 y A vit. 200 000 iUClinical types; Tipical Modified: who received IG (0.2 ml/kg) Atipical : who had been vaccinated Immunodeficiencies; Giant cell pneumonia

Measles vaccine (MMR, MR and measles vaccines).

The MMR vaccine is a live, attenuated (weakened), combination vaccine that protects against the measles, mumps, and rubella viruses

Children should get 2 doses of MMR vaccine: The first dose at 12-15 months of age The second dose at 4-6 years of age

A second dose of the vaccine is recommended to protect those 5% who did not develop immunity in the first dose and to give "booster" effect to those who did develop an immune response.

Group A Beta-hemolytic streptococGAS

Gram + coccusBeta-hemolytic, Alfa-hemolytic, Gamma-hemolytic Beta-hemolytics are Bacitracine sensitive

Due to C=CARBONHYDRATE layer ; LANCEFİELD clasification . A-H ve K-T

Due to M proteins, 75 types

Scarlet fever or Scarlatina

An exotoxin-mediated disease arising from group A beta-hemolytic streptococcal infection.

Ordinarily, scarlet fever evolves from a tonsillar/pharyngeal focus, although the rash develops in fewer than 10% of cases of "strep throat."

Exotoxin-mediated streptococcal infections range from localized skin disorders to the systemic rash of scarlet fever to the uncommon but highly lethal streptococcal toxic shock syndrome

Frequency

In the past century, the number of cases of scarlet fever has remained high, with marked decrease in case-mortality rates secondary to widespread use of antibiotics.

Transmission usually occurs via airborne respiratory particles that can be spread from infected patients and asymptomatic carriers.

You can get scarlet fever through direct contact with throat mucus, nasal discharge, or saliva of an infected person.

The infection rate increases in overcrowded situations

(schools, institutional settings).

Epidemiology

The organism is able to survive extremes of temperature and humidity, which allows spread by fomites.

Geographic distribution of skin infections tends to favor warmer or tropical climates and occurs mainly in summer or early fall in temperate climates.

Immunity

Immunity, which is type specific, may be induced by a carrier state or overt infection.

In adulthood, incidence decreases markedly as immunity develops to the most prevalent serotypes.

Complications ( ARA) are more common

GAS

(GAS) is the most prevalent;

15% All ages

20-30% 5-18 years of age

50% During epidemics

Pathophysiology Group A beta-hemolytic streptococcal replication site in

scarlet fever are the tonsils and pharynx Clinically indistinguishable, scarlet fever may follow

streptococcal infection of the skin and soft tissue surgical wounds (surgical scarlet fever), or the uterus ( puerperal scarlet fever)

Group A beta-hemolytic streptococci secrete a number of toxins and enzymes

Erythrogenic toxin causes the pathognomonic rash of scarlet fever

Local lesions reveal a characteristic inflammatory reaction, specifically hyperemia, edema, and polymorphonuclear cell infiltration.

Scarlet fever Incubation period : 1-7 days A fever of 101 degrees Fahrenheit (38.3 C) or higher   . decreases 5-6 days later without AB

24 hours later Penicillin A red and sore throat that can have white or yellow patches  Swollen glands in the neck Headache, throat and abdominal pain In addition to the symptoms of strep throat

Nausea, and vomitingENANTHEM: Tonsills, pharinx, tongue; edema and covered with exudateIn severe cases membranous ulcers on tonsills Special appearance; 1-4 days White strawberry, 4 days later red strawberry

Scarlet Fever- rash A flush face with a pale area around the lips a red rash appears on the sides of chest and abdomen. It may spread to cover most of your body. This rash appears as tiny, red pinpoints and has a rough

texture like sandpaper When pressed on, the rash loses color or turns white. It is redder in the creases of the elbows, arm pits, and

groin areas. The rash lasts about 2-7 days. The skin on the tips of your fingers and toes often peels

after rash resolves

Diagnosis Typical clinical features Isolation of agent Culture Serologic tests ( streploenzim ), ASO A rapid antigen test (“rapid strep test”) to see if

there is a group A strep infection. Others: Leucocytosis Dominant PMN, %5-10 eosinophils

Treatment for scarlet fever

Penicillin V oral 3-4 dose 10 days

<27 kg 125 mg/dose

> 27 kg 250 mg/dose

Benzathine Penicillin G IM one dose

<27 kg 600.000 U

>27 kg 1.200.000 U

Eritromycine 40 –50 mg/kg/day 3 -4 dose

Amoxicillin and Ampicillin

< 15 kg 125 mg/dose 3 dose

> 15 kg 250 mg/dose 3 dose

ComplicationsEarly complications Cervical adenitis Otitis media Sinusitis Bronchopneumonia Rarely mastoiditis, sepsis, osteomyelitis.Late complications: 1-3 weeks later ARA ( % 3) AGN; 12,4 and 49 are nephritogenic

Late Complications

Untreated group A strep infections can result in

Rheumatic fever and post-streptococcal glomerulonephritis (PSGN)

Rheumatic fever can develop about 18 days after a bout of strep throat and causes heart disease with or without joint pain

It can be followed months later by Sydenham chorea, a disorder in which the muscles of the torso, arms, and legs move involuntarily in a dancing and jerky manner

PSGN is an inflammation of the kidneys that may follow an untreated strep throat but more often comes after a strep skin infection

VARICELLA-ZOSTER VIRUSEpidemiology :Highly contagious very common between 5-10 years of age 90% infection till 10 years of age Spreads during winter and fall Droplet infection, by air wayIncubation Period : 14-16 days(2-3 weeks) Transmission may occur 2 days before rash and after 7.

day of rash Chicken pox is spread easily through coughs or sneezes

of ill individuals, or through direct contact with secretions from the rash.

Following primary infection there is usually lifelong protective immunity

Varicella-zoster virus (VZV)- chickenpox

Chickenpox follows initial exposure to the virus and is typically a relatively mild, self-limited childhood illness with a characteristic exanthem

Approximately 1 per 4000 children develops VZV encephalitis, an acute neurologic disorder with potentially severe complications

In addition, immunocompromised children (those receiving chemotherapy for leukemia or those with advanced HIV infection) can develop disseminated VZV infection, a potentially fatal complication

Chickenpox After primary infection, VZV remains dormant in

sensory nerve roots for life Upon reactivation, the virus migrates down the sensory

nerve to the skin, causing the characteristic painful dermatomal rash

After resolution, many individuals continue to experience pain in the distribution of the rash (postherpetic neuralgia)

In addition, reactivation of VZV infection can cause a spectrum of atypical presentations, ranging from self-limited radicular pain without rash to spinal cord disease with weakness

SYMPTOMS Some kids have a fever, abdominal pain, sore

throat, headache, or a vague sick feeling a day or 2 before the rash appears

These symptoms may last for a few days, and fever stays in the range of 100°–102° F (37.7°–38.8° C), though in rare cases may be higher

Younger kids often have milder symptoms and fewer blisters than older children or adults

Rash Chickenpox causes a red, itchy skin rash that usually

appears first on the abdomen or back and face, and then spreads to almost everywhere else on the body, including the scalp, mouth, nose, ears, and genitals.

The rash begins as multiple small red bumps that look like pimples or insect bites

They develop into thin-walled blisters filled with clear fluid, which becomes cloudy

The blister wall breaks, leaving open sores, which finally crust

Stages

Rash stage Macules Papules Vesicles Pustules Crusts (scabs)

Scars

COMPLICATIONS The spots do not usually scar unless they are

badly scratched Some spots become infected with bacteria in

about 1 /10 cases. An ear infection develops in about 1/20 cases Pneumonia and encephalitis are rare

complications Thrombocytopenia

Other serious complications Reye's syndrome Myocarditis Glomerulonephritis Appendicitis Hepatitis Pancreatitis Henoch–Schönlein purpura Orchitis Arthritis Inflammation of various parts of the eye

CONGENİTAL VARİCELLA

Low birth weight, cortical atrophy, convulsion,mental retardation, chorioretinitis, microcephaly, intracranial calsification and sicatrisial lesions on trunk and extremities

Mother who gets varicella (5 days before or

later ) The newborn born with 15-20 % VARİCELLA SYNDROME transplacental antibody deficiency Mortality rate is 20-30%

Treatment Treatment is mainly aimed at easing symptoms Plenty to drink to avoid dehydration. paracetamol or ibuprofen to ease fever, headaches,

and aches and pains Calamine lotion put on the spots may ease itching Antihistamine tablets or liquid medicine for children

over one year old Keep fingernails cut short to stop deep scratching Antiviral medication is used for teenagers and patients

who have higher risk of complications (Vidarabin, Acyclovir)

Vaccination Included in routine childhood immunisation programme

in certain countries such as USA and Canada Currently, there are some plans to make immunisation

against chickenpox routine for children in Turkey Some countries offer vaccine to certain groups:.

Healthcare workers

To people close contact with people with a poor immune system

Brothers and sisters of children on chemotherapy

Shingles The rate of occurrence is about 5 /1000

population Immunosuppression increases the risk The risk of postherpetic neuralgia increases

with age Approximately 50% of patients older than 60

years may have temporary or prolonged pain syndrome

The frequency of VZV infection may decrease as the immunized children become adults

Pathophysiology

The host immunologic mechanisms suppress replication of the virus

Reactivation can occur if host immune mechanisms are compromised: medications, illness, malnutrition, natural decline in immune function with aging

Upon reactivation, the virus migrates along sensory nerves and produces sensory loss, pain, and other neurologic complications

If motor nerve roots are also involved, weakness can develop in addition to sensory changes

Herpes zoster (shingles) Commonly affects a thoracic dermatome After a prodromal illness of pain and paresthesias,

erythematous macules and papules develop and progress to vesicles within 24 hours

The vesicles eventually crust and resolve Pain and sensory loss are the usual symptoms Motor weakness results when the viral activity

extends beyond the sensory root to involve the motor root

Cases of actual monoplegia due to varicella-zoster virus (VZV) brachial plexus neuritis have been reported