Childhood Exanthemata Dr. Philip G. Murphy Consultant Microbiologist, AMNCH,Tallaght.

Aetiology Exanthem = exterior rash Measles Rubella Varicella (chickenpox) Scarlet fever Parvovirus HH6 (Kawasaki Disease) Other childhood fevers:Mumps, Whooping cough, Diphtheria NSROC

Measles Rubeola (RNA morbillivirus) Incubation: 7-14 d Prodrome: 4 -5 d before rash fever, malaise, coryza, sneezycough, Koplik spots1-3 d before rash Rash: day 4-7 of illness starts behind ears, forehead, around mouth dusky red, florid maculopapular rash spreads over trunk and limbs. Lasts 5 d. Infectivity: prodrome to 4 d after the rash Transmission: respiratory droplet or direct contact Complications: ears & OM, lungs & pneumonia conjunctivitis CNS encephalitis at d 10, SSPE after several years

Measles Highly contagious acute viral illness caused by a paramyxovirus, genus Morbillivirus One of the leading causes of child mortality in developing countries - 10% of all deaths of children < 5 years. Measles eradication possible – no longer endemic in U.S. Europe: Outbreaks reported in Germany 1996, 1999 and 2000, Netherlands 1999 (2600 cases and 3 deaths).

Measles vaccination Measles vaccination in Ireland since 1985 Vaccination rates of 95% necessary to eliminate spread Vaccination coverage of 70 – 80% at 24 months of age in the Eastern Regional Health Authority Outbreak of measles occurred between December 1999 and July 2000. Majority of cases in TCH catchment area.

Eastern Regional Health Authority

Number (%) Total number attending TCH 355 Number admitted to TCH 111 Underlying chronic or acute illnesses 29 (26) Number admitted to ICU 13 (11) Mortality 3 Range Median Inpatient stay 1 - 43 5 ICU stay 1 - 28 6

MMR Status of Measles Cases in Northern Area Health Board (n=567):

Indication for admission

Symptoms and Signs 95% 95% 84% Number Of Patients 54% 40% 39% 33% 8% 54% 40% 39% 33% 8% Apnoea Exanthem Cough Vomiting Otitis Media Febrile Seizure Pyrexia Conjunctivitis Diarrhoea

Control Public Health Outbreak Control Team set up by NDSC Measles/Mumps/Rubella (MMR) vaccination Brought forward to 12 months of age Given at 6 months in our area Repeated at 15 months Second MMR brought forward to 4 years of age Opportunistic vaccination in schools and creche Recalled non-attenders Press releases

Future Oireachtais Committee Report Co-ordinator to oversee vaccine program Dedicated administrative and nursing staff Modernisation of Civil Registration Service Personal public service number Improved IT at health board level Vaccine information statements to parents Continuous immunisation campaigns in media until rate > 95% Guidelines for future outbreaks

Varicella (chickenpox, shingles) Incubation: 12-21 d Prodrome: 1 d before rash fever, malaise Rash: oval macule progressing to macule and then pustules which heal and crust. Appears as crops centrally then peripherally Other: may be marked fever for 2-3 d., then settles Infectivity: 5d before to 5 d after the rash Transmission: respiratory droplet or direct contact Complications:Rare:encephalitis after 10d pneumonia especially immune suppressed 20 bacterial skin infection Shingles Diagnosis: EM, CFT Treatment: aciclovir, topical disinfectants, ZIG if immune suppressed

Rubella Incubation: 14-23 d Prodrome: none or mild fever1d before rash Rash: none or for 1-3 d a pink macular rash on face and trunk otherwise well sub-occipital lymphadenopathy arthralgia /polyarthritis in older child or adult rarely thrombocytopaenia Infectivity: 7d before to 5 d after the rash Transmission: respiratory droplet or direct contact Complications: in utero - congenital rubella syndrome, deafness,cataracts, cardiac abnormalities hepatomegaly, splenomegaly, purpura. 30% mortality. 25% if exposure in first 4months, 60-80% in 1st month rarely encephalitis at 10d

Kawasaki Disease Unknown aetiology ?? Infective fever, rash, conjunctivitis, hand/feet dorsae induration stomatitis, strawberry tongue, lymphadenopathy coronary artery narrowing - aneurysm, thrombosis and MI desquamation in recovery Rx: Immuneglobulin

Erythema infectiosum (Fifth Disease, Slapped ckeek syndrome) Parvovirus B19, ssDNA, 22 nm diameter Rash on cheeks, flitting and later lace-like on trunk More severe in adults with arthritis and lymphadenopathy benign course and rare complications transient marrow depression and rarely aplastic crisis

Exanthem subitum Roseola infantum;Sixth Disease Human Herpes virus 6 commonly seroconversion by 2 years 3-5 d fever, urti 20% exanthem: classic maculopapular rash common in CNS but ? Role in multiple sclerosis

Scarlet fever Aetiology; Streptococcus pyogenes (Group A) Pathogenesis: erythrogenic toxin Incubation: 1-3 d Prodrome: 1-2 d fever,sorethroat,headache,flushed cheeks Rash: punctate erythematous central and blanches Signs: circumoral palor, strawberry tongue, desquamation post rash Infectivity: up to 3 weeks or 24h after pen Transmission: respiratory Complications: septicaemia, endocarditis, OM, Quinsy rheumatic fever, acute nephritis