Pediatric Exanthems.

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1 Pediatric Exanthems

2 بيماران مبتلا به تب و راش جلدي به توجه فوري نيازمند مي باشند
بيماران مبتلا به تب و راش جلدي به توجه فوري نيازمند مي باشند . علل اين تظاهرات ممكن است عوامل كشنده و حياتي باشند و تشخيص هاي افتراقي فراواني كه براي آن مطرح مي باشند درخواست تستهاي باليني زيادي را توسط پزشكان متخصص ايجاب مي نمايد . گرفتن شرح حال باليني كامل ، مسافرت اخير بيمار ، سابقه تماس با حيوان يا انسان مبتلا به عفونت ، يا مصرف ماده خاصي نكات كليدي مهمي براي كشف علت بيماري مي باشند .

3 مشخصه راش جلدي نيز در معاينه فيزيكي بسيار ارزشمند است از آنجائيكه معمولاً قبل از آماده شدن جواب كشت ها و آزمايشات اين بيماران بطور تجربي (empiric ) درمان مي گيرند لذا محدود كردن دامنه تشخيص هاي افتراقي كمك كننده مي باشد . در طبقه بندي انواع مختلف و شايع راش هاي جلدي به ترتيب انواع پتشي ، ماكولوپاپولر ، بولوس و زيكولر ، اريتماتوس ، كهير تقسيم بندي مي شود .

4 Pediatric Exanthems Six separate childhood exanthems were defined from what was once called the “measles.” In the early part of the 20th century, these were often referred to by number However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.

5 Classic Childhood Exanthems
Measles Scarlet fever Rubella (“German measles”) Atypical scarlet fever Erythema Infectiosum Roseola Measles and scarlet fever were the first two to be separated. Rubella (German measles) was called “third disease”; atypical scarlet fever was “fourth disease”; erythema infectiosum was (and is) “fifth disease,” and roseola was “sixth disease.”

6 Today, dozens of exanthems are recognized:
Adenovirus Anthrax Mononucleosis Colorado tick fever Mumps Cat-scratch fever Rat-bite fever Rocky Mountain spotted fever Relapsing fever Meningococcemia Typhus Hand-foot-mouth disease However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.

7 #1- Measles Virus: Rubeola
Demographics Winter or spring Infancy to young adulthood 8- to 12-day incubation Epidemics until 96% immunized Prodrome 2–4 days. High fever, cough, coryza, conjunctivitis, photophobia, Koplik spots, lethargy, sneezing.

8 #1 Measles Rash and Disease
Enanthem: Koplik spots  =  gray pinheads, ring of erythema, buccal mucosa. 0.5–2d. Exanthem: erythematous blanching macules. Starts forehead, spreads downward Confluent by 72 hr Spares palms, and soles, 4–6 days. Toxic appearance.

9 Fig. 81.6 Measles. Pink macules and minimally elevated papules with confluence

10 #1- Measles Diagnosis Leukopenia, IgG and IgM serologies, acute and convalescent titers Treatment Symptomatic. Antipyretics. In severe disease, vitamin A.

11 #1- Measles Complications Otitis media, diarrhea, pneumonia (common in atypical rubeola). Rarely, laryngo-tracheobronchitis, myocarditis, encephalitis. Subacute sclerosing panencephalitis

12 #1- Measles Prevention Vaccinate all at 12–18 mo.
Two doses for 13 years and older. Post-exposure vaccine if immuno-compromised VZIG if pregnant, premature, or immunocompromised

13 #2- Scarlet Fever Streptococcal, erythrogenic toxin.
Demographics 1 to 10 yr Prodrome 2 to 4 days Scarlet fever was a feared disease in the nineteenth and early twentieth centuries, when it was more virulent, but presently scarlet fever is usually benign. Virulent strains may appear in the future. New waves of scarlet fever are associated with an increase in frequency of Streptococcus pyogenes clones carrying variant gene alleles encoding streptococcal pyrogenic exotoxin A (scarlet fever toxin).[14] Previous exposure to the toxin is required for expression of disease. Streptococcal pyrogenic exotoxin A causes disease by enhancing delayed-type hypersensitivity to streptococcal products.

14 #2- Scarlet Fever Rash and Disease
Strawberry tongue Exudative pharyngitis Generalized; spares palms and soles Pinpoint papules Desquamation of the tips of the fingers and toes Scarlet fever was a feared disease in the nineteenth and early twentieth centuries, when it was more virulent, but presently scarlet fever is usually benign. Virulent strains may appear in the future. New waves of scarlet fever are associated with an increase in frequency of Streptococcus pyogenes clones carrying variant gene alleles encoding streptococcal pyrogenic exotoxin A (scarlet fever toxin).[14] Previous exposure to the toxin is required for expression of disease. Streptococcal pyrogenic exotoxin A causes disease by enhancing delayed-type hypersensitivity to streptococcal products.

15 Strawberry tongue: red tongue with prominent papillae

16 diffuse red sandpaper-like

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18 Pastia line

19 #2 Scarlet Fever Diagnosis
Group A streptococcal positive throat culture Elevated WBC count and ESR Treatment : penicillin, cephalosporins, erythromycin, ofloxacin, rifampin, or the newer macrolides Scarlet fever was a feared disease in the nineteenth and early twentieth centuries, when it was more virulent, but presently scarlet fever is usually benign. Virulent strains may appear in the future. New waves of scarlet fever are associated with an increase in frequency of Streptococcus pyogenes clones carrying variant gene alleles encoding streptococcal pyrogenic exotoxin A (scarlet fever toxin).[14] Previous exposure to the toxin is required for expression of disease. Streptococcal pyrogenic exotoxin A causes disease by enhancing delayed-type hypersensitivity to streptococcal products.

20 #3- Rubella Virus: Rubivirus (Rubella) Demographics Prodrome
5–14 yr before vaccines Now teens and young adults 2- to 3-wk Prodrome Mild catarrhal symptoms, often overlooked. Marked tender lymphadenopathy seen 24 hr before rash

21 #3 Rubella Rash and Disease
Exanthem: Starts face, spreads by 24 hr to trunk, extremities. Day 1: 1- to 4-mm macules, usually distinct, sometimes reticular. Day 2: pinpoint papules. Day 3: clears. Sometimes mild desquamation. Low-grade fever, pruritus possible.

22 Rubella

23 #3 Rubella Diagnosis Treatment Acute and convalescent titers
rubella IgM antibody (esp. for exposed pregnant women) Treatment Symptomatic. NSAIDs for arthritis.

24 #3 Rubella Complications
Self-limiting polyarthritis in girls, young women. Hands and wrists, large joint effusions. Fetuses of nonimmune women infected may have deafness, eye, cardiac and endocrine anomalies, and retardation.

25 #3 Rubella Prevention Vaccine at 12–15 mo Second dose at 11–12 yr.
Immune globulin not indicated.

26 #5- Erythema Infectiosum
Virus: Parvovirus B19 Demographics: Spring 5–17 yr 4- to 21-d incubation Prodrome Low-grade fever, headache, malaise.

27 #5- Erythema Infectiosum Rash and Disease
“Slapped cheeks” facial erythema with abrupt onset –conjunctivitis- Circumoral and perioral pallor, sparing of nasal bridge. Body develops pale maculopapular exanthem; may involve palms and soles. Lasts 3–5 daysand can be brought by stresses 2-39 Days Gloves and Socks syndrome (only hands and feet affected)-also hemorrhagicAtypically, Papular-Purpuric

28 Fig. 81. 7 Erythema infectiosum
Fig. 81.7 Erythema infectiosum. Lacy, reticulated skin eruption over the arm during the second stage of the exanthem. Courtesy of Yale Residents Slide Collection.

29 #5- Erythema Infectiosum
Diagnosis IgM and IgG serologies, acute and convalescent antibody titers, DNA hybridization ANA-RF-Aplastic Anemia Fetal Hydrops Treatment Symptomatic. IVGG and transfusions if hematologic complications

30 #5- Erythema Infectiosum Complications
In anyone: Henoch-Schonlein purpura, Polyarteritis nodosa Infectious mononucleosis. In HIV+ or those with hemolytic anemia: aplastic anemia. In pregnancy: fetal hydrops or stillbirth.

31 #5- Erythema Infectiosum
No vaccine. No isolation once symptomatic (not contagious); Pregnant women should avoid outbreak sites for 3 wk and get serologic testing.

32 #6- Roseola Virus: HHV-6 /HHV-7 Demographics 0–3 yr Prodrome:
3–5 d intermittent fever to 40.5°C. Child appears well.

33 #6- Roseola Rash and Disease
Exanthem: 0–2 d after defervesces 1- to 5-mm rose macules with pale areola densest on neck and trunk. Can get confluent. Lasts 1–3 d. Enanthem: pinpoint papules or streaks on uvula, soft palate. LAD, periorbital edema, cough, headache, coryza, abdominal pain.

34 #6- Roseola Diagnosis Treatment Clinical.
Specific IgM and IgG for acute and convalescent titers not widely available. Treatment Symptomatic. Antipyretics for fever.

35 #6- Roseola Complications
Febrile seizures. More rarely: mononucleosis neonatal hepatitis fatal hemophagocytic syndrome encephalitis thrombotic thrombocytopenic purpura Prevention: none

36 Hand, Foot, and Mouth disease aka Papular-purpuric gloves and socks syndrome
Virus: Enteroviruses Demographics Summer (less pronouncedin tropics) 6 mo to 13 yr Prodrome Brief. Sore throat, anorexia, malaise, low-grade fever.

37 Hand, Foot, and Mouth disease Rash and Disease
Enanthem: Oral mucosal vesicles that erode to form ulcers 2 mm to 2 cm in diameter. Painful! Exanthem: 3- to 7- mm vesicles on dorsal hands, feet, and sometimes palms, sole. Tender, pruritic, or asymptomatic

38 B19 Fig. 81.8 Papular-purpuric gloves and socks syndrome. Erythematous patches with petechiae on the palms. This patient also had superficial erosions of the palate and pharynx

39 Fig. 81. 4 Hand-foot-and-mouth disease
Fig. 81.4 Hand-foot-and-mouth disease. Note the oval or football-shaped vesicle on an erythematous base centrally.

40 Fig. 81. 5 Enteroviral exanthem
Fig. 81.5 Enteroviral exanthem. Note prominent petechial component of the exanthem in this 10-year-old boy.

41 Hand, Foot, and Mouth disease
Diagnosis Clinical Specific serotype testing should clinician suspect a particular enterovirus Treatment Symptomatic. Analgesia to help child with oral intake, steroids for itch

42 Hand, Foot, and Mouth disease Complications
Rare with Coxsackie A and B. CNS or pulmonary complications possible with enterovirus-71.

43 DDx of an Erythematous Maculopapular Rash
Rubella    Rubeola    Scarlet fever    Kawasaki disease    Secondary syphilis    Drug eruption    Coxsackie virus    ECHO virus  Adenovirus     Infectious mononucleosis    Parvovirus    Meningococcemia    Toxoplasmosis    Serum sickness    Rickettsial disease (eg, Rocky Mountain Spotted fever)    Roseola

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45 Fig. 81. 9 Unilateral laterothoracic exanthem
Fig. 81.9 Unilateral laterothoracic exanthem. Erythematous macules and papules involving the left axilla, lateral trunk and flank. The exanthem progressed to a bilateral distribution, but maintained left-sided predominance.

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47 Virus/Syndrome: Demographics Prodrome Rash and Disease Diagnosis Treatment Complications

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49 Fig. 81. 13 Kawasaki disease. A Strawberry tongue and cheilitis
Fig  Kawasaki disease. A Strawberry tongue and cheilitis. Courtesy of Robert Hartman, M.D. B Perineal eruption of Kawasaki disease. Accentuation of erythema in the genital or perineal region is a characteristic cutaneous finding. View PDF

50 Impetigo - this usually takes the form of itchy lesions with macules, vesicles, bullae, pustules and gold-coloured crusts caused by Staphylococcus aureus or group A beta-haemolytic streptococci.2 Staphylococcal scalded skin syndrome(appears as scalded skin, due to focal staphylococcal infection – eg phage type 71 – releasing an exotoxin).3

51 Pediatric Exanthems In antiquity, these illnesses were all lumped together. Eventually, a distinction was made between measles and pox (with growing clarity over about a millennium). However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.

52 Poxes Chickenpox and Smallpox
the other two classic childhood exanthems recognized as separate from each other in the 18th century. These both had blisters, or pox, that set them apart from the red rashes of the other group However, what people called the “pox” and what was then called the “measles” are now known to each include a variety of distinct diseases.

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54 Varicella (chickenpox) - vesicles (initially papules, often not noticed), appearing as 'drops of water'. Superficial, thin-walled with surrounding erythema rapidly changing to pustules and crusts. Appears in crops with all stages represented. First appears on face and scalp then spreads to trunk and extremities. Crusts fall off in 1-3 weeks leaving pink base. Initial fever is classically high before becoming low grade. Beware of dyspnoea/cough which may indicate varicella zoster virus (VZV) pneumonitis.1

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56 Herpes simplex virus infection (HSV) - eczema herpeticum (HSV infection superimposed on pre-existing, often mild, eczema causing an eruption of crusty vesicles and eczematous patches).

57 Lesions in DIFFERENT stages of
development • Rapid evolution of lesions • Centripetal (central) distribution • Lesions rarely on palms or soles • Patient rarely toxic or moribund

58 Erythema multiforme, classically appearing as target lesions (erythematous ring with central bulla)2
Stevens-Johnson syndrome4 Toxic epidermal necrolysis4 Pompholyx (on hands/feet)5

59 Is it red but not scaly (and NOT purpuric)? Consider:
Cellulitis Kawasaki's disease Scarlet fever and the viral exanthemas e.g.: Roseola infantum – (Sixth Disease) Primary human herpes viral (HHV6 & 7) infection. Most common age is under two years, frequent cause of infantile febrile seizures. Small blanchable pink macules and papules found on trunk and neck. Associated with high fever prior to defervescence or fifth disease) caused by Parvovirus B19 Measles - presents as erythematous & appearance of rash on fourth day. Often asymptomatic. Erythema infectiosum - (slapped cheek syndrome macules and papules, initially discrete may become confluent on face, neck and shoulders. On mucous membranes, Koplik's spots (tiny bluish-white papules with erythematous areola) may develop. Also, upper respiratory tract infection with cough, malaise and fever subsiding as rash increases (measles prodrome = the 4 C's - cough, coryza, conjunctivitis and cranky++!) Rubella (German measles) pink macules and papules starting on forehead and spreading to face, trunk and extremities on first day Fades from face on second day and rest of body by third day. Petechiae on soft palate before rash. Low fever.

60 Scarlet fever (=scarlatina) exotoxin mediated rash (Group A Streptococcus) - sore throat then general erythema (classically with perioral sparing), followed by confluent petechiae in skin folds (Pastia sign) due to increased capillary fragility. Strawberry tongue (initially white, then red). Skin desquamation (peeling) frequently follows rash

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62 Is it red and purpuric? Meningococcal meningitis (not common but should be excluded) Early, in 75% cases 2-10mm macular or maculopapular rash that blanches on pressure becomes apparent within first 24 hours of disease; sparsely distributed on face, trunk and lower extremities.18 Use 'glass test' to assess 'blanchability' of rash by placing glass tumbler against lesions and applying pressure. Later the petechiae in centre of macules become haemorrhagic. Henoch-Schonlein purpura Idiopathic thrombocytopaenic purpura (ITP), leukaemia and other haematological disorders20 Trauma, non-accidental Injury Enterovirus infections21 Miscellaneous conditions: Warts2 Verrucas Head lice7

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65 Classic Reference Exanthems and Drug Eruptions
Habif: Clinical Dermatology, 4th ed., Copyright © 2004 Mosby, Inc.

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67 Review article: Pediatric exanthems
Clinics in Family Practice Volume 5 • Number 3 • September 2003 Copyright © 2003 W. B. Saunders Company Jeffrey D. Wolfrey, MD * William H. Billica, MD Scott H. Gulbranson, MD Alaina B. Jose, MD Mark Luba, MD Andrew Mohler, MD Cheryl Pagel, MD Jarrett K. Sell, MD