1. Pediatric Exanthems

2. 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

3. Review of Terminology of Skin Lesions

4. 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

5. 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

6. Description of Rashes
PUSTULE
MACULE
NODULE
VESICLE

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

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

9. “1st Disease” - Measles Paramyxovirus At risk:
Preschool age children unvaccinated
School age children in whom vaccine failed
Season: late winter/spring
Incubation: days
Infectious: 1-2 days before prodrome to 4 days after onset of rash

10. 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

11. Koplik’s Spots

12. Koplik’s Spots
                                                                                                         

13. Exanthem of Measles

14. Exanthem of Measles
                                                                             

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

16. “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

17. Scarlet Fever – Clinical Features
Abrupt onset fever, headache, vomiting, malaise, sore throat
Enanthem
Bright red oral mucosa
Palatal petechiae
Tongue changes

18. Strawberry Tongues

19. Scarlet Fever - Exanthem
                                                                                                

20. Scarlet Fever - Exanthem

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

22. “3rd Disease” - Rubella Togavirus At risk: Unvaccinated adolescents
Season: late winter/early spring
Incubation: days
Infectious period: 5-7 days before rash to 3 to 5 days after rash

23. 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

24. Rubella - Exanthem

25. Rubella - Exanthem

26. 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

27. “4th Disease” – Filatow Dukes Disease
Obsolete
Probably now better defined as another clinical entity

28. “5th Disease” – Erythema Infectiosum
Human Parvovirus B19
At risk: school age children
Season: sporadic
Incubation period: days
Infectious period: up until onset of the rash

29. 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

30. EI: Slapped Cheek

31.                                                                                                          
EI: Exanthem

32. EI: Exanthem

33. 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)

34. “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

35. 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

36. Roseola - Exanthem

37. Roseola - Exanthem