1. CASE 5: “RASH JUDGMENT”

2. Questions to be answered
How are rashes classified?
What infectious conditions are to be entertained in Michelle’s case?
Are there non-infectious conditions that may present with rashes?
In view of the general presentation, what is the most likely diagnosis of Michelle’s case?
Discuss the possible complications of her condition
Discuss the treatment of Michelle’s case
Discuss the measure/s necessary to prevent infection with the viral exanthems that present with maculopapular rash

3. “RASH JUDGMENT”
Michelle is a 10-year old girl with fever for the last five days. Associated symptoms include brassy cough and coryza, watery diarrhea and decreased appetite. Two days later, she was noted to have “sore eyes” and irritability.
The mother could not recall the child’s immunizations except that she was given the last vaccines at the health center at age 4 months

4. “RASH JUDGMENT”
On examination, she looked tired and ill, and had a temperature of 390C; CR 88/min. and RR 26/min.. She had a rash that started 8 – 12 hrs. earlier behind the ears and on the face then spread down the body. The rash was erythematous with fine macules and papules. Conjunctivitis was prominent. On examination of the buccal mucosa, small 1-mm.white papules were seen opposite the 2nd molars.

5. “RASH JUDGMENT”
2 days later, the white spots disappeared and the palms and soles were involved in the erythematous rash which later became brownish. This was later followed by a fine branny desquamation first occurring in the face later involving the body.

6. Q1: How are rashes classified ? (judged)

7. RASH JUDGMENT
A exanthem is a skin eruption occurring as an integral part of an infectious disease. The corresponding changes in the mucous membranes is an enanthem
Accurate diagnosis not always possible on preliminary examination- judgment should be deferred until rash develops

8. Morphologic types or Components of a rash
Macule is a circumscribed discoloration of the skin. Often evolve into papules. Papules are small nodular elevations of the skin
Vesicles are small blisters containing clear fluid. Pustules are small elevations of the skin containing pus
Maculopapular rash
Vesiculopustular rash

9. Morphologic types or Components of a rash
Petechiae are small hemorrhages beneath the epidermis. Ecchymoses are larger areas of hemorrhage
Color Atlas of Infectious Diseases,
Emond & Rowland

10. Other components Crust/scab – congealed exudate on the skin
Wheal – localised effusion of fluid into the skin causing a raised, white or pinkish-white zone with a halo of erythema
Erythema – a diffuse or localised red ness of the skin

11. Vital information necessary in the diagnosis of exanthematous illnesses
Exposure
Season
Incubation period
Age
Previous exanthem
Relation of rash to fever
Adenopathy
Type of rash
Distribution of rash
Progression of rash
Exanthems
Other associated symptoms or Prodrome
Laboratory tests
Feigin and Cherry Textbook of Pediatric Infectious Diseases

12. Basis for Rash Judgment:
Prodromal period
Rash
Presence of pathognomonic or other diagnostic signs
Laboratory diagnostic tests

13. Q2: What infectious conditions are to be entertained in Michelle’s case?

14. Conditions that present with Maculopapular rash
1. Measles
Prodromal period:
The rash is preceded by a 3 or 4 day period of fever, conjunctivitis, coryza and cough
Rash:
reddish brown, appears on the face first and progresses downward to involve the trunk and extremities in sequence

15. Measles
Rash (cont.): The eruption fades by the 5th or 6th day with brownish staining first followed by branny desquamation. The hands and feet do not desquamate
Brownish discoloration

16. Measles Pathognomonic sign: Koplik’s spots
Detected on the mucosa of the cheeks opposite the molars, where they resemble coarse grains of salt on the surface of the inflamed membrane.
Histologically are small necrotic patches in basal layers of the mucosa with serum exudation and mononuclear cell infiltration

17. Measles course

18. Conditions that present with Maculopapular rash
2. Rubella (Postnatal)
Prodromal period:
In children there are no prodromal period. The appearance of the rash and preceding lymphadenopathy may be the first obvious sign of disease.
Adults and adolescents may have a variable period of malaise and low-grade fever before the rash appears
Rubella rash
Rubella course

19. Postnatal Rubella Rash:
Not distinctive; initially discrete, delicate pink macules beginning on face and neck and progresses downward to the trunk & extremities more rapidly than measles. On the third day the face is usually clear
Does not desquamate

20. Postnatal Rubella
Forchheimer spots – red spots are often seen on the palate
Exceptionally profuse in this patient

21. Rubella Diagnostic sign: Laboratory diagnosis:
lymphadenopathy (particularly postauricular and occipital) is a common manifestation, but it also occurs in other diseases
Laboratory diagnosis:
positive throat culture for rubella virus and rise in antibody level are helpful diagnostic aids

22. Congenital Rubella Syndrome
“Blueberry muffin” rash: a purpuric rash may present at birth or develop within 48 hrs.
May be accompanied by bleeding from the mucosal surface

23. Conditions that present with Maculopapular rash
3. Roseola infantum
Prodromal period:
a 3 or 4 day period of high fever and irritability precedes the rash which appears as the temperature falls to normal

24. Roseola infantum (HHV 6)
Rash:
typically discrete rose-red maculopapules that frequently appear on the chest and trunk first and then spread to involve the face and extremities.
The eruption usually disappears within 2 days. Occasionally within several hours

25. Roseola infantum Diagnostic sign: Laboratory diagnostic test:
The coincidental appearance of the rash with defervescence in an infant is distinctive
Laboratory diagnostic test:
none locally commercially available

26. Conditions that present with Maculopapular rash
4. Erythema infectiosum:
Rash: erupts in 3 stages
1. Red, flushed cheeks with circumoral pallor (“slapped check” appearance)
2. Maculopapular eruption over upper and lower extremities (the rash assumes a lacelike appearance as it fades)

27. Erythema infectiosum
Lacelike pattern
of rash
Slapped-face appearance

28. Erythema infectiosum Rash (cont.) Diagnostic sign:
3. An evanescent stage characterized by subsidence of the eruption followed by recurrence precipitated by a variety of skin irritants
Diagnostic sign:
suggested by the slapped-face appearance in a well child
Laboratory diagnosis:
future serologic tests to confirm parvovirus B19

29. Conditions that present with Maculopapular rash
5. Infectious mononucleosis
Rash – pinkish maculopapular, often mistaken for rubella
Tends to be patchy and heavier on the limbs

30. Infectious mononucleosis
Diagnostic signs:
a triad of membranous tonsillitis, lymphadenopathy and splenomegaly suggests this
Laboratory diagnostic test:
blood smear positive for abnormal lymphocytes.
Monospot test and heterophil agglutination (Paul-Bunnell) test are positive

31. Infectious mononucleosis
Hoagland’s sign: lid edema

32. 6. Enteroviral Infections
Prodrome:
Echovirus 16 (Boston exanthem) prodrome resemble exanthem subitum but fever lower
Fever & constitutional symptoms in Echovirus 4, 6 & 9 may precede but usually coincide with rash appearance
Rash:
May be maculopapular, petechial and vesicular eruptions with Coxsackie A9, A16,A10, A5,B3 and B5
ECHOvirus type 19 infection
Cochsackievirus infection

33. 7. Mucocutaneous Lymph Node Syndrome (Kawasaki disease)
Prodrome:
A nonspecific febrile illness with sore throat precedes the rash by 2 – 5 days
Rash:
Generalized, erythematous, maculopapular. The palms and soles are swollen and reddened, eventually peeling after several days or weeks.

34. Mucocutaneous Lymph Node Syndrome (Kawasaki disease)
Rash (cont.)
Dryness with erythema of the lips (red strawberry tongue), mouth and tongue accompanies bilateral conjunctival injection

35. Mucocutaneous Lymph Node Syndrome (Kawasaki disease)
Conjunctivitis
Bilateral, bulbar, generally nonpurulent
Cervical lymphadenopathy
Usually unilateral
Not explained by other known disease process

36. Mucocutaneous Lymph Node Syndrome (Kawasaki disease
Periungual desquamation or
Perianal desquamation may follow in the subacute phase

37. Diagnostic Criteria for Kawasaki Disease
Fever lasting for at least 5 days
Presence of at least 4 of the ff. 5 signs:
Bilateral bulbar conjunctival injection, generally nonpurulent
Changes in the mucosa of the oropharynx, including injected pharynx, injected and/or dry fissured lips, strawberry tongue
Changes of the peripheral extremities, such as edema and/or erythema of the hands or feet in the acute phase; or periungual desquamation in the subacute phase
Rash, primarily truncal; polymorphous or nonvesicular
Cervical adenopathy, > 1.5 cm., usually unilateral lymphadenopathy illness not explained by other known disease process

38. 8. Staphylococcal Scalded Skin Syndrome
Prodrome:
None
Fever and irritability occur at the time of onset of the rash
Rash:
Generalized, erythematous, scarlatiniform eruption with sandpaper-like texture

39. Staphylococcal Scalded Skin Syndrome
Rash (cont)
The erythema is accentuated in the skin folds.
The skin is tender and within 1-2 days, bullae appear and the epidermis separate into large sheets, revealing a moist, red, shiny surface underneath (Nikolsky sign)
Ritter’s disease

40. Staphylococcal Scalded Skin Syndrome variants
+ Nikolsky sign
Lyell’s disease
Lyell’s disease
Toxic Epidermal Necrolysis

41. Staphylococcal Scalded Skin Syndrome variants
Newborns – Ritters disease or Pemphigus neonatorum
Older children and adults – Lyell’s disease or Toxic Epidermal Necrolysis
TEN differentiated from SSS by intraepithelial splitting at the dermoepidermal junction
TEN usually drug-induced from phenytoin, phenobarbital, sulfonamides,
penicillin
Toxic epidermal Necrolysis

42. Staphylococcal Scalded Skin Syndrome variants
Diagnostic sign:
An associated staphylococcal infection e.g. Impetigo or purulent conjunctivitis may be present
Laboratory diagnostic tests:
Culture of skin positive for phage group II

43. 9. Staphylococcal Toxic Shock Syndrome
Prodrome:
High fever, headache confusion, sore throat, vomiting, diarrhea and shock may precede or may be associated with the rash
Rash
There are no characteristic features of the rash
Occurs most prominently in the trunk & extremities
Associated with edema and desquamation
Poor capillary refill in TSS

44. Staphylococcal Toxic Shock Syndrome
Diagnostic signs:
The scarlatiniform eruption is associated with high fever, toxicity and a shock-like state
Laboratory tests:
Cultures of various mucosal surfaces or purulent lesions should be positive for Staphylococcus aureus

45. 10. Typhoid fever Rash: Rose spot Step-ladder temperature chart
Typically appear towards the end of the 1st week
Present in 50% of adults but less common in children
Difficult to detect on dark skin
Districuted over abdomen, chest and back but rarely seen in face, hands or feet
Step-ladder temperature chart

46. Q3: Are there non-infectious conditions that may present with rashes?

47. Noninfectious conditions
Drug eruptions/toxic erythemas
Sunburn
Miliaria
No prodromal periods
Sunburn rashes confined to the areas not protected by clothing
Miliaria: fine punctiform lesions are chiefly confined to the flexor areas. Rash not usually generalized and does not desquamate

48. Drug Eruptions…Others
Erythema multiforme
from
sulphonamide
Malar “butterfly
Rash” of Systemic
Lupus erythematosus
Urticaria
caused by
Penicillin

49. Q4: In view of the general presentation, what is the most likely diagnosis of Michelle’s case?

50. Task 5: Discuss the possible complications of her condition

51. Task 6: Discuss the treatment of Michelle’s case

52. Task 7: Discuss the measure/s necessary to prevent infection with the viral exanthems that present with maculopapular rash

53. Task 8: Enumerate possible Key Learning points in Michelle’s case

54. CASE 5: “RASH JUDGMENT”