Pediatric Exanthems

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

Review of Terminology of Skin Lesions

The Basics of Rashes Distribution Configuration Description Evolution Localized vs. Systemic Sun exposed areas? Configuration Round Serpiginous Coalesce Description Macular, Papular, Petechial Evolution Where it began and where it ended Associated Findings

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

Description of Rashes PUSTULE MACULE NODULE VESICLE

Definitions Exanthem – a skin eruption occurring as a symptom of a general disease Enanthem – eruptive lesions on the mucous membranes

Classic Childhood Exanthems Measles (Rubeola) Scarlet Fever Rubella (German Measles) Filatow-Dukes Disease Erythem Infectiousum Roseola Infantum

“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

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

Koplik’s Spots

Koplik’s Spots                                                                                                            

Exanthem of Measles

Exanthem of Measles                                                                                

Complications of Measles Otitis Media Bronchopneumonia Encephalitis Pericarditis Subacute sclerosing panencephalitis – late sequellae due to persistent infection of the CNS

“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

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                                                                                                   

Scarlet Fever - Exanthem

Scarlet Fever - Complications Purulent Otitis media Sinusitis Peritonsillar/retropharyngeal abscesses Cervical adenitis Nonsuppurative sequalae Rheumatic Fever Acute glomerulonephritis

“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

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

Rubella - Exanthem

Rubella - Exanthem

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

“4th Disease” – Filatow Dukes Disease Obsolete Probably now better defined as another clinical entity

“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

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

EI: Slapped Cheek

                                                                                                          EI: Exanthem

EI: Exanthem

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)

“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

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

Roseola - Exanthem