1. Dr(Mrs) M.S.Panapitiya Consultant Paediatrician
Fever & rashes
Dr(Mrs) M.S.Panapitiya
Consultant Paediatrician

2. why
Viral exanthum
Serious illness

3. Main features
Well child / ill child
Erythematous / haemorrhagic rash

4. Diagnostic clues
Association with fever
Distribution
Morphology

5. Classfication of rashes
Mobiliform rashes
Scarlantiform rashes

6. Mobilliform rash Rash that looks like measles Patients with
Kawasaki disease
drug reactions
The rash consists
macular lesions
red
2-10 mm in diameter
may be confluent
papular lesions
solid
elevated above the rest of the skin

7. Scarlatiniform rash Has the pattern of scarlet fever
has innumerable small red papules
Patients with other conditions such as
Kawasaki
disease
viral infections
drug reaction

8. Aetiology
VIRAL INFECTIONS
BACTERIAL INFECTIONS
NONINFECTIVE

9. Viral infections Chicken pox Hand foot mouth disease Measles Rubella
Fifth disease
Sixth disease
Dengue fever

11. Fifth Disease Erythema infectiousum Parvovirus B19
The preceding four exanthems were
1. Measles
2. Scarlet fever
3. Rubella
4. Atypical Scarlet fever ( Filatov-Dukes disease) 6. Roseola infantum (sixth disease)

12. Fifth Disease Benign, self-limited exanthematous illness of childhood.
The prodromal phase
low-grade fever
headache
mild upper respiratory
tract infection

13. Fifth Disease Characteristic rash erythematous facial flushing
occurs in three stages
erythematous facial flushing
"slapped-cheek" appearance.

14. extremities as a diffuse macular erythema
2. Spreads rapidly to the
trunk and proximal
extremities as a diffuse
macular erythema

15. Central clearing of macular lesions occurs
giving the rash a lacy,
reticulated appearance.

16. Fifth Disease Palms and soles are spared,
more prominent on extensor surfaces
rash resolves spontaneously without desquamation

18. Roseola infantum Exanthem subitum Sixth disease
Human herpes virus 6 (HHV-6)

19. Roseola infantum Primary HHV-6 infection occurs early in life.
Peak acquisition of primary HHV-6 infection, from 6-15 m of age
By 3-5 yr, % of children are seropositive

20. Roseola infantum The prodromal period usually asymptomatic but may
include
mild upper respiratory tract signs
mild conjunctival redness
cervical or, less frequently, occipital
lymphadenopathy
mild palpebral edema.

21. Roseola infantum Clinical illness 101-106°F with an average of 103°F
irritable and anorexic
Seizures may occur in 5-10% of children
Infrequently abdominal pain, vomiting,
and diarrhea.
Fever persists for 3-5 days, and then typically resolves rather abruptly (crisis)

22. Roseola infantum A rash appears within 12-24 hr of fever resolution
Begins as discrete, small (2-5 mm), slightly raised pink lesions on the trunk and spreads to the neck, face, and proximal extremities
Not pruritic, and no vesicles or pustules
remain discrete but occasionally may become almost confluent.
After 1-3 days, the rash fades.

24. Measles
(rubeola)

25. Measles Measles has three clinical stages Incubation stage 10-12 days
Prodromal stage days
Disease stage days

26. Measles prodromal phase characterized by low-grade to moderate fever
conjunctivitis
coryza
dry cough
red mottling on the hard & soft palate
Koplik spots

27. Measles Koplik spots The pathognomonic sign of measles,
appear by 2-3 days
Grayish white dots, usually as small as grains of sand
Opposite the lower molars
They appear and disappear rapidly, usually within hr.

28. The temperature rises abruptly as the rash appears
Measles
EXANTHEMATOUS PHASE
The temperature rises abruptly as the rash appears
neck, behind the ears, along the hairline, and on the posterior parts of the cheek

29. Measles Lesions macular, maculopapular confluent,haemorrhagic
Spreads rapidly over the entire face, neck, upper arms, and upper part of the chest within the first 24 hr

30. Measles Mx
admit
iv fluids
vit A
antiotics
NUTRITION

31. Measles Complictions pneumonia diarrhoea malnutrition blindness
encephalitis
death

33. RUBELLA The incubation period is 14-21 days
(German or three-day measles)
The incubation period is days
The prodromal phase of mild catarrhal symptoms is shorter than that of measles and may go unnoticed
Two thirds of infections are subclinical.

34. RUBELLA Lymphadenopathy. An enanthem
most characteristic sign
retroauricular, posterior cervical, and
occipital
An enanthem
appears in 20% of patients just before
the onset of the skin rash.
discrete rose-colored spots on the soft
palate (Forchheimer spots)
Lymphadenopathy.

35. Rubella Exanthem It begins on the face and spreads quickly.
Discrete maculopapules are
present in large numbers
Spread rapidly over the entire
body, usually within 24 hr.
May be confluent
The eruption usually clears by
the third day.
Rubella without a rash has been
described.

36. Hand foot and mouth disease
Vesicular exanthum
CHICKEN POX
Hand foot and mouth disease

37. Hand foot and mouth disease
Coxsackievirus A
Coxsackie B viruses
Enterovirus 71

38. Hand foot and mouth disease
It is usually a mild illness, with or without low-grade fever.
The oropharynx is inflamed and contains scattered vesicles on the tongue, buccal mucosa, posterior pharynx, palate, gingiva, and/or lips.
These may ulcerate, leaving 4-8 mm shallow lesions with surrounding erythema.

40. Hand, foot, and mouth disease
Develop the rash on the
palms of the hands,
soles of the feet,
maybe on buttocks.
Rash is not itchy,
Starts out as small, flat, red dots
turn into bumps or blisters(3-7mm)

41. Hand, foot, and mouth disease
They are generally more common
on the extensor surfaces
Vesicles resolve in about 1 week

44. Mx
Symptomatic
No specific therapy

45. CHICKEN POX Patients are contagious 24-48 hr before the rash appears
Vricella-Zoster Virus
Patients are contagious hr before the rash appears
and until vesicles are crusted,
usually 3-7 days after onset of rash

46. CHICKEN POX Prodromal phase 24- 48 hr before the rash
malaise, headache, anorexia
fever - variable
- resolves 2-4 days after
the onset of the rash

47. CHICKEN POX The rash often appears first on the scalp, face, or trunk.
It can then spread over the
entire body.
Ulcerative lesions involving the oropharynx are common

48. CHICKEN POX The initial exanthem Intensely pruritic
Vricella-Zoster Virus The initial exanthem
The initial exanthem
Intensely pruritic
Erythematous macules
Papular stage
Blisters on a pink base
Dry brown crusts
New waves of blisters often spring up as the illness progresses

49. CHICKEN POX
Vricella-Zoster Virus
Varicella is a more serious disease with higher rates of complications and deaths among infants, adults, and immunocompromised patients.

50. Newborn with varicella
Newborns have particularly high mortality around the time of delivery.
Maternal varicella one week before or 2 days after birth frequently results in the newborn developing severe varicella
The initial infection is intrauterine, although the newborn often develops clinical chickenpox postpartum.

51. Newborn with varicella
Rx : ZSIG
IV Acyclovir

52. CONGENITAL VARICELLA SYNDROME
Up to 2% of fetuses whose mothers had varicella in the first 20 weeks of pregnancy may demonstrate VZV embryopathy
Fetuses infected
at 6-12 wk of gestation appear to have
maximal interruption with limb development
at wk may have eye and brain involvement

53. Skin Eye Brain Limbs Stigmata of Varicella-Zoster Virus Fetopathy
Cicatricial skin lesions
Hypopigmentation
Microphthalmia
Cataracts
Chorioretinitis
Optic atrophy
Skin
Eye
Brain
Limbs
Microcephaly
Hydrocephaly
Calcifications
Aplasia of brain
Hypoplasia of an extremity
Motor and sensory deficits
Absent deep tendon reflexes

54. Varicella vaccine Live virus vaccine
Recommended for children at mo
Can be given at any age
Children 12 mo to 12 yr receive a single vaccine dose
Adolescents and adults require 2 vaccine doses, a minimum of 4 wks apart

55. Breakthrough varicella
2-6 weeks after vaccination
Could be due to either the wild or vaccine strains
Usually very mild
Potentially infectious

56. Scarlet fever
Upper respiratory tract infection associated with a characteristic rash
Infection with pyrogenic exotoxin producing group A streptococcus

57. Scarlet fever
The rash
appears within hr after onset of upper respiratory symptoms
begins around the neck and spreads over the trunk and extremities

58. Scarlet fever
Diffuse, finely papular, erythematous eruption producing a bright red discoloration
Blanches on pressure

59. Scarlet fever
More intense along the creases of the elbows, axillae, and groin P

60. Scarlet fever
Cheeks may be erythematous with pallor around the mouth.

61. Scarlet fever Pharynx is red
The tongue is usually coated and the papillae are swollen
After desquamation, the reddened papillae are prominent, giving the tongue a strawberry appearance.

63. Scarlet fever
After 3-4 days, the rash begins to fade and is followed by desquamation
Sheetlike desquamation may occur around the free margins of the fingernails, the palms, and the soles.

65. Scarlet fever Treatment Group A streptococcus is sensitive to
penicillin, and resistant strains have never
been encountered.
Penicillin is, therefore, the drug of choice
(except in patients who are allergic to
penicillin)
Treatment with oral penicillin V for 10 days is
recommended
It must be taken for a full 10 days even
though there is symptomatic improvement
in 3-4 days

66. Toxic shock syndrome Toxic shock syndrome is caused by
a toxin produced by certain types of Staphylococcus bacteria.
A similar syndrome, called toxic shock-like syndrome (TSLS), can be caused by Streptococcal bacteria.

67. Toxic shock syndrome The onset is abrupt high fever vomiting diarrhea
sore throat
headache
myalgia

68. Toxic shock syndrome Very ill Alteration in the level of consciousness
Oliguria, hypotension
progress to shock
Disseminated intravascular coagulation

69. Toxic shock syndrome Exanthum
A diffuse erythematous macular rash (scarlatiniform) appears within 24 hr
Hyperemia of pharyngeal& conjunctival, mucous membranes
Strawberry tongue is common

70. Kawasakie disease Diagnostic criterias
Fever lasting for at least 5 days
Presence of at least four of the following five signs:
Fever lasting for at least 5 days

71. Bilateral bulbar conjunctival injection, generally nonpurulent

72. the oropharynx, injected pharynx red, dry & fissured lips
2. Changes in the mucosa of
the oropharynx,
injected pharynx
red, dry & fissured lips
strawberry tongue

73. 3.Changes of the peripheral extremities
Edema and/or erythema of
the hands or feet in the
acute phase
Periungual desquamation in
the subacute phase

74. 4.Rash, primarily truncal polymorphous but nonvesicular
Rash of various forms (maculopapular, erythema multiforme, or scarlatiniform) with accentuation in the groin area

75. 5.Cervical adenopathy,
≥1.5 cm
usually unilateral
nonpurulent

76. Mycoplasma pneumoniae
Skin lesions include a variety of exanthems, most notably
Maculopapular rashes
Erythema multiforme
Stevens-Johnson syndrome

77. Dengue fever rash
A transient, macular, generalized rash that blanches under pressure may be seen during the first hr of fever.
A generalized, morbilliform, maculopapular rash appears that spares the palms and soles. Rarely there is edema of the palms and soles.
Petecial rash - Usually found on the limbs this rash is as a result of bleeding under the skin surface.
Bright red rash - skin becomes florid and bright red in appearance. there will be some 'normal' areas of skin which are unaffected.

78. Thank you

79. ?TRANSIENT APLASTIC CRISIS
The incubation period for is shorter than for erythema infectiosum because it occurs coincident with the viremia.
B19-induced aplastic crises occur in patients with all types of chronic hemolysis
These patients are ill with fever, malaise, and lethargy and have signs and symptoms of profound anemia
Rash is rarely present.
TRANSIENT APLASTIC CRISIS.

80. C0NGENITAL INFECTION
(PARVOVIRUS B19)
Primary maternal infection is associated with nonimmune fetal hydrops and intrauterine fetal demise
The mechanism of fetal disease appears to be a viral-induced red cell aplasia at a time when the fetal erythroid fraction is rapidly expanding.
The second trimester seems to be the most sensitive period, but fetal losses are reported at every stage of gestation

82. Oral HSV primary infection
probably the most common cause of stomatitis in children 1-3 yr of age,
The symptoms may appear abruptly, with pain in the mouth, salivation, fetor oris, refusal to eat, and fever, often as high as °C
Fever and irritability may precede the oral lesions by 1-2 days.
The initial lesion is a vesicle which is seldom seen because of its early rupture.
The residual lesion is 2-10 mm in diameter and is covered with a yellow-gray membrane.
the tongue and cheeks are most commonly involved, no part of the oral lining is
Submaxillary lymphadenitis is common.
The acute phase lasts 4-9 days and is self-limited

83. reatment
Any foreign materials, such as tampons, vaginal sponges, or nasal packing, will be removed. Sites of infection (such as a surgical wound) will be drained.
The goal of treatment is to maintain important body functions. This may include:
Antibiotics for any infection (may be given through an IV)
Dialysis (if severe kidney problems are present)
Fluids through a vein (IV)
Methods to control blood pressure
Intravenous gamma globulin may help in severe cases

84. Dukes' disease or fourth disease
An exanthem-producing infectious disease of childhood of unknown aetiology.
Synonym: Filatov's disease, fourth disease,

85. Signs and tests
No single test can diagnose toxic shock syndrome.
The diagnosis is based on several criteria: fever, low blood pressure, a rash that peels after 1-2 weeks, and problems with the function of at least three organs.
In some cases, blood cultures may be positive for growth of S. aureus.
Treatment